Perifollicular Elastolysis: A Systematic Review of Clinical Characteristics, Histopathology, and Therapeutic Outcomes

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript is comprehensive and interesting. Please find my comments below:
1. Title is ok.
2. In the abstract, please add future research recommendations.
3. In the introduction, please add more recent research about the histopathology and therapeutic treatment of Perifollicular Elastolysis.
4. Add references in every subsection 2.1-2.5
5. Add more references, more than 50 articles is good (in the present form it is only 42 references).
6. What demographic patterns (age, sex, ethnicity) are associated with perifollicular elastolysis?
7. Are there consistent associations with acne, inflammation, or other dermatologic conditions?
8. What pathogenic mechanisms (e.g., inflammatory destruction, enzymatic degradation) have been proposed? If possible, please add any explanation in discussion section.
9. What evidence exists regarding the effectiveness or lack of response to medical, procedural, or observational management strategies?
10. In Table 7, there is only one reference, is it possible to add more references?

Author Response

 Reviewer 1

The manuscript is comprehensive and interesting. Please find my comments below:

1. Title is ok.

Reply

Thank you for your positive assessment. We are pleased that you found the manuscript comprehensive and interesting. We appreciate your confirmation that the title is appropriate.

2. In the abstract, please add future research recommendations.

Reply

Thank you for this suggestion. We have revised the abstract to include a brief recommendation for future research, aligned with the limitations and conclusions of the review.

3. In the introduction, please add more recent research about the histopathology and therapeutic treatment of Perifollicular Elastolysis.

Reply

Thank you for this helpful suggestion. We have revised the Introduction to incorporate more recent evidence on the histopathology and therapeutic management of perifollicular elastolysis, including updated descriptions of elastic-fiber changes demonstrated by special stains and recent procedural treatment reports, with appropriate citations.

4. Add references in every subsection 2.1-2.5

Reply

Thank you for this suggestion. We have revised the Methods section (Subsections 2.1–2.5) to include appropriate methodological references in each subsection, including PRISMA/PRISMA-S for reporting and search methods, the Cochrane Handbook for systematic review methodology, and JBI critical appraisal tools for risk-of-bias assessment.

5. Add more references, more than 50 articles is good (in the present form it is only 42 references).

Reply

Thank you for this suggestion. We have updated the manuscript to include additional relevant and up-to-date references, increasing the total number of cited sources to at least 50, while ensuring that all added citations directly support the corresponding statements in the text.

6. What demographic patterns (age, sex, ethnicity) are associated with perifollicular elastolysis?

Reply

Thank you for this important comment. We have revised the Results section to summarize demographic patterns across included studies using extractable quantitative data (age distribution, sex proportions, and the frequency of reporting for ethnicity and Fitzpatrick phototype), and we have cited the contributing studies accordingly.

7. Are there consistent associations with acne, inflammation, or other dermatologic conditions?

Reply

Thank you for this important question. We revised the Results section to summarize the most consistently reported clinical associations (particularly acne history), and to report the frequency of other dermatologic/inflammatory contexts (e.g., keloids, atopic dermatitis, Behçet’s/pseudofolliculitis, and mechanical trauma), with supporting citations.

8. What pathogenic mechanisms (e.g., inflammatory destruction, enzymatic degradation) have been proposed? If possible, please add any explanation in discussion section.

Reply

Thank you for this suggestion. We have expanded and refined the Discussion (Section 4.2) to more explicitly summarize proposed pathogenic mechanisms—including inflammatory destruction, enzymatic degradation (protease/MMP-related pathways), microbial hypotheses, and mechanical/immunologic contributors—while clarifying the level of supporting evidence.

9. What evidence exists regarding the effectiveness or lack of response to medical, procedural, or observational management strategies?

Reply

Thank you for this important comment. We revised the Results and Discussion to more clearly summarize the available evidence on management strategies—medical (topical/conservative), procedural interventions, and observational approaches—while emphasizing the overall low certainty of evidence and frequent absence of standardized outcome measures.

10. In Table 7, there is only one reference, is it possible to add more references?

Reply

Thank you for this comment. Table 7 reflects the currently available evidence for that specific item, and only one eligible study met our predefined inclusion criteria for inclusion in this table. We have clarified this issue in the table caption/footnote and verified that no additional eligible primary studies reported comparable data to be added.

Reviewer 2 Report

Comments and Suggestions for Authors

Comments on Cosmetics-4120105

This is a well-conducted and timely systematic review addressing an under-recognized dermatologic entity. With clearer diagnostic framing, a more cautious interpretation of treatment findings, and stronger methodological guidance for future research, the manuscript could make a valuable contribution to the dermatology and cosmetic science literature.

1. Search strategy: language restriction

The restriction to English-language publications should be explicitly acknowledged as a potential source of language bias, especially given that early or foundational reports may originate from non-English-speaking regions.

2. Outcome measures are not standardized

Heterogeneity in outcome reporting is correctly identified, but the manuscript would be strengthened by proposing a core outcome set for future PE studies, for example: lesion count and/or standardized severity grading; standardized photography protocols; validated scar scales; patient-reported outcomes (symptoms, QoL, satisfaction). This would increase the methodological value of the review beyond summarizing existing studies.

3. Risk of bias / certainty of evidence: integrate into interpretation

• While the JBI tools appear appropriately selected, the implications of bias are not sufficiently incorporated into the conclusions. Many included studies lack consecutive recruitment, control groups, and standardized outcomes; therefore, treatment-effect interpretations may be overstated.
• Please add a concise narrative (or a GRADE-style narrative summary) explaining how the overall low-to-moderate quality of the available evidence limits confidence in the reported treatment effectiveness.
• Please re-evaluate the risk-of-bias assessment and consider summarizing it quantitatively (e.g., Yes = 1 point; No/Unclear = 0 points), followed by an overall conclusion on the methodological quality of the included studies, highlighting total scores and key recurring limitations.

4. Eligibility criteria need more detail (Section 2.1)

Please clarify inclusion/exclusion criteria more explicitly (population, diagnostic criteria, study designs, outcomes, and follow-up requirements). This will improve reproducibility and transparency.

5. Terminology and abbreviation consistency

If “PE” is defined as an abbreviation, please use “PE” consistently throughout the manuscript (including tables/figures) and avoid switching between alternative terms (e.g., “papular acne scars” vs. “PE”) unless you are explicitly explaining synonyms.

6. Meta-analysis statement is inaccurate

The statement “sixteen studies were included in the meta-analysis” is misleading if no meta-analysis was performed. Please replace with “systematic review” (or clarify if a quantitative synthesis was conducted).

7. Introduction needs stronger study context

In the Introduction, please add more examples of existing evidence (clinical trials, observational studies, and any relevant in vitro/in vivo studies, if applicable) to better justify the review and clarify the evidence landscape.

8. Tables 1–3 readability

• Tables 1–3 are comprehensive but dense. The authors should consider simplifying the column structures, adding brief table legends/footnotes explaining key variables, summarizing key patterns in the main text and moving highly detailed elements to supplementary material.
• Table 1 improvements
  • Please add region/country of each study.
  • Consider splitting clinical outcomes into clearer sub columns, for example: baseline characteristics; follow-up duration / timepoints; treatment regimen; outcome at follow-up
  • Add/clarify “number of patients” as a dedicated column.

9. Add a schematic/graphical summary

A schematic illustration summarizing clinical appearance → histopathology → pathogenesis → treatment options would substantially improve reader comprehension and would fit well as a graphical abstract or summary figure.

10. Section ordering

Please revise subsection numbering/order for clarity: move current Section 2.2 into 2.1 and shift the current 2.1 accordingly (or reorganize so the PRISMA/search strategy and eligibility flow logically).

11. Language polishing

Overall language quality is good. Minor grammatical polishing (e.g., article usage, reducing sentence length in the Discussion) would further improve readability.

12. Reference formatting

Please carefully check the reference formatting to match the journal style. Several references (e.g., #2, #8, etc.) appear inconsistent or messy.

 

Author Response

Reviewer 2

This is a well-conducted and timely systematic review addressing an under-recognized dermatologic entity. With clearer diagnostic framing, a more cautious interpretation of treatment findings, and stronger methodological guidance for future research, the manuscript could make a valuable contribution to the dermatology and cosmetic science literature.

1. Search strategy: language restriction

The restriction to English-language publications should be explicitly acknowledged as a potential source of language bias, especially given that early or foundational reports may originate from non-English-speaking regions.

Reply

Thank you for highlighting this important point. We have revised the manuscript to explicitly acknowledge the English-language restriction as a potential source of language bias in the Limitations section and noted that early or regionally published foundational reports may have been missed, which could affect the completeness and generalizability of the evidence synthesized.

2. Outcome measures are not standardized

Heterogeneity in outcome reporting is correctly identified, but the manuscript would be strengthened by proposing a core outcome set for future PE studies, for example: lesion count and/or standardized severity grading; standardized photography protocols; validated scar scales; patient-reported outcomes (symptoms, QoL, satisfaction). This would increase the methodological value of the review beyond summarizing existing studies.

Reply

Thank you for this constructive suggestion. We have expanded the Discussion to propose a pragmatic core outcome set for future PE studies, including lesion quantification, standardized photography, validated scar scales, patient-reported outcomes, and standardized safety/recurrence reporting, to improve comparability and strengthen the methodological contribution of this review.

3. Risk of bias / certainty of evidence: integrate into interpretation

While the JBI tools appear appropriately selected, the implications of bias are not sufficiently incorporated into the conclusions. Many included studies lack consecutive recruitment, control groups, and standardized outcomes; therefore, treatment-effect interpretations may be overstated.

Please add a concise narrative (or a GRADE-style narrative summary) explaining how the overall low-to-moderate quality of the available evidence limits confidence in the reported treatment effectiveness.

Please re-evaluate the risk-of-bias assessment and consider summarizing it quantitatively (e.g., Yes = 1 point; No/Unclear = 0 points), followed by an overall conclusion on the methodological quality of the included studies, highlighting total scores and key recurring limitations.

Reply

Thank you for this suggestion. We have revised the Results section to include a quantitative summary of the JBI assessments (Yes=1; No/Unclear=0; NA excluded) and to highlight recurrent methodological limitations across included studies (e.g., unclear consecutive recruitment, lack of control groups, and non-standardized outcomes), which informs interpretation of treatment findings.

4. Eligibility criteria need more detail (Section 2.1)

Please clarify inclusion/exclusion criteria more explicitly (population, diagnostic criteria, study designs, outcomes, and follow-up requirements). This will improve reproducibility and transparency.

Reply

Thank you for this comment. We revised Section 2.1 to clarify eligibility criteria in greater detail, including the operational diagnostic criteria (clinical and histopathologic requirements), eligible outcomes, and follow-up requirements, to improve reproducibility and transparency.

5. Terminology and abbreviation consistency

If “PE” is defined as an abbreviation, please use “PE” consistently throughout the manuscript (including tables/figures) and avoid switching between alternative terms (e.g., “papular acne scars” vs. “PE”) unless you are explicitly explaining synonyms.

Reply

We agree. We have revised the manuscript to ensure consistent use of the abbreviation after first definition. “Perifollicular elastolysis (PE)” is defined at first mention, and PE is now used consistently throughout the text, tables, and figure captions. Alternative terms (e.g., “papular acne scars/scarring”) are retained only when reporting the terminology used in the original source studies, and are explicitly presented as synonymous with PE.

6. Meta-analysis statement is inaccurate

The statement “sixteen studies were included in the meta-analysis” is misleading if no meta-analysis was performed. Please replace with “systematic review” (or clarify if a quantitative synthesis was conducted).

Reply

Thank you for noting this. We have corrected the wording throughout the manuscript by replacing “meta-analysis” with “systematic review” and clarifying that no quantitative meta-analysis was conducted due to heterogeneity.

7. Introduction needs stronger study context

In the Introduction, please add more examples of existing evidence (clinical trials, observational studies, and any relevant in vitro/in vivo studies, if applicable) to better justify the review and clarify the evidence landscape.

Reply

Thank you for this suggestion. We have strengthened the Introduction by explicitly framing the existing evidence by study type (observational, interventional, and mechanistic/experimental) and adding representative examples, thereby clarifying the evidence landscape and reinforcing the rationale for this systematic review.

8. Tables 1–3 readability

Tables 1–3 are comprehensive but dense. The authors should consider simplifying the column structures, adding brief table legends/footnotes explaining key variables, summarizing key patterns in the main text and moving highly detailed elements to supplementary material.

Table 1 improvements

Please add region/country of each study.

Consider splitting clinical outcomes into clearer sub columns, for example: baseline characteristics; follow-up duration / timepoints; treatment regimen; outcome at follow-up

Add/clarify “number of patients” as a dedicated column.

Reply

We appreciate your constructive advice. Simplifying the column structure, adding concise table legends/footnotes to define key variables and abbreviations, and moving highly granular study descriptors (e.g., extended baseline narratives and detailed intervention parameters) to Supplementary Tables S1–S2 improved readability in Tables 1–3. Table 1 was also updated to include study country/regions and clarify patient/sample denominators with an “n” column. Table 3's subcolumns (treated n with follow-up, treatment regimen, follow-up timepoint(s), outcome, and safety) were clarified. We also provided brief in-text summaries of key patterns and referred readers to the supplementary tables.

9. Add a schematic/graphical summary

A schematic illustration summarizing clinical appearance → histopathology → pathogenesis → treatment options would substantially improve reader comprehension and would fit well as a graphical abstract or summary figure.

Reply

Thank you for this suggestion. We have added a graphical summary (**Figure 2**) summarizing the **clinical appearance, histopathology, proposed pathogenesis, and treatment options**. It is placed in the Discussion immediately before the Limitations section and cited in the text.

10. Section ordering

Please revise subsection numbering/order for clarity: move current Section 2.2 into 2.1 and shift the current 2.1 accordingly (or reorganize so the PRISMA/search strategy and eligibility flow logically).

Reply

Thank you for this helpful suggestion. We have reorganized the Methods section to improve logical flow by moving the search strategy content to Section 2.1 and shifting the eligibility criteria to Section 2.2, with subsequent subsections renumbered accordingly.

11. Language polishing

Overall language quality is good. Minor grammatical polishing (e.g., article usage, reducing sentence length in the Discussion) would further improve readability.

Reply

Thank you for this comment. We have carefully polished the manuscript for grammar and readability, including article usage and sentence length (particularly in the Discussion), and we also obtained professional English-language editing through Editage.

12. Reference formatting

Please carefully check the reference formatting to match the journal style. Several references (e.g., #2, #8, etc.) appear inconsistent or messy.

Reply

Thank you for noting this. We have carefully reviewed and corrected the reference list to ensure full consistency with the journal’s formatting requirements, including author formatting, journal titles, volume/issue, page/article numbers, and DOI presentation.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript has been well revised in response to the reviewers' comments. It can be accepted for publication in the present form.