Acne scars lead to emotional embarrassment, poor self-esteem, social isolation, low confidence, body image alterations, unemployment, lowered academic performance, and exacerbation of the psychiatric disease of anxiety or depression. Acne scars treatment must consider the cost of treatment, the severity of lesions, physician goals, patient expectations, side-effect profiles, psychological or emotional effects on the patient, and prevention measures.
Various treatment modalities include topical therapies, chemical peelings, micro-needling, microdermabrasion, subcision, autologous ⁄ non-autologous dermal fillers, and energy-based technology such as fractioned ⁄ non-fractionated lasers, ablative/non-ablative lasers, pigment or vascular-specific lasers, and minor surgical procedures. Whatever the choice, it should be clearly understood by both physicians and patients that, at present, improvement of scarring, rather than total cure, is the goal. Any intervention or treatment aims to improve scars, not for a total cure or perfection.
Types of Acne Scars
Two examples of excess tissue presence are hypertrophic scars and keloids. Hypertrophic scars are confined within the margins of the original injury. These scars are most prevalent within the first couple of months post-injury and then, in contrast to keloids, tend to typically mature with occasional spontaneous regression. However, some have also worsened. These scars are often less bothersome, and treatment may or may not be needed based on severity.
Keloids are a human-specific phenomenon characterized by collagen’s disproportionate creation and deposition with an excess outside the original injury margins. They are found on the chest, back, shoulders, and ears. These lesions are very persistent and are familial and genetic influences. Clinically, there may be a pain, itching, burning, or a limited range of motion. The other cause of scars, loss, or tissue damage is proved by the three primary acne scars: an ice pick, rolling, and boxcar.
The ice picks scars are usually more minor in diameter (less than 2 mm) and deep with tracts into the dermis or subcutaneous tissue. Although the orifice is smaller and steep-sided, a broad base may evolve into a depressed, boxcar scar. Boxcar scars are round to oval depressions with sharply demarcated vertical edges, like varicella scars. They are clinically wider at the surface than icepick scars and do not taper to a point at the base.
They may be shallow (0.1-0.5 mm) or deep (≥ 0.5 mm) and are often 1.5 to 4.0 mm in diameter. Soft rolling scars can be circular or linear, are often greater than 4 mm in diameter, and have gently sloped edges that merge with normal-appearing skin. Hard rolling scars occur from the dermal tethering of otherwise relatively normal-appearing skin and are usually wider than 4 to 5 mm. Abnormal fibrous anchoring of the dermis to the subcutis leads to superficial shadowing and a rolling or undulating appearance to the overlying skin.
Why is Acne Scars Treatment Needed?
Acne scars lead to emotional debilitation, embarrassment, poor self-esteem, social isolation, preoccupation, low confidence, altered social interactions, body image alterations, identity difficulties, anger, frustration, confusion, unemployment, lowered academic performance, exacerbation of the psychiatric disease, anxiety, and depression. Treatment of the true scars resulting from acne must reflect several considerations by the physician.
Cost of treatment, the severity of lesions, physician goals, patient expectations, side-effect profiles, psychological or emotional effects, and prevention measures should all play a role. The therapies/techniques must be individualized, considering many factors like age, gender, Fitzpatrick skin phototype, site of scars, clinical type of acne scars, grading of scars, socioeconomic constraints, and psychological and physical health of the patient. The goal of any intervention is for improvement, not for a total cure or perfection.
Dermatologists Only Skincare Products
Pre-conditioning Treatment Program of the skin with Vitamin A and lactic acid with or without bleaching cream or lotion (Hydroquinone, arbutin, licorice Kojic acid, and Azelaic acid) has become a standard protocol at MSI. Pre-conditioning programs are essential to tighten the skin, reduce wound healing, and decrease the chance of dyspigmentation. It is essential in darkly pigmented skin treated with ablative resurfacing techniques. I should treat the affected skin for several weeks before any ablative procedure. In the first 2-3 weeks, the skin goes through an accommodation phase and is often red and irritated.
Another treatment modality used focuses on hypertrophic scars, and to a lesser degree, the keloid is silicone dressing. There is variable support to the silicone itself, with results more likely attributable to occlusion or hydration. Although the mechanism of action of silicone sheeting has not been completely elucidated, it is an effective means of treating and preventing hypertrophic and keloid scars. The treatments have included intralesional corticosteroids, vascular laser, fluorouracil (and other cytotoxic) injections for moderate hypertrophic scars.
More recently, intralesional verapamil at a concentration of 2.5 mg/mL (0.5–2mLinjected volume depending on the size of the scar) or topical imiquimod has been suggested as a postoperative adjunctive treatment for surgical Excision of keloidal. Intralesional cytotoxic, including fluorouracil, bleomycin, and mitomycin, are used for hypertrophic and keloidal scars. Fluorouracil can be used at a 50 mg/mL concentration and has been mixed 80:20 with low-strength intralesional steroids. However, it may also be used alone, with approximately 1 mL used in each scar.
Micro-needling Skin Treatment
The basis of micro-needling (MN) relies on physical injury. It has been proposed that the trauma generated by needle penetration in the skin induces dermis regeneration. This results in the deposition of collagen by fibroblasts. The technique of micro-needling has been well-exploited to increase the penetration of drugs across the skin barrier. Microinjections and micro-needling are successful in skin rejuvenation, hair loss, and scar therapy.
Acne Scars Filler Injection
Volume change correction includes focal dermal filling of individual scars and volume fillers (e.g., fat Transfer, off-the-shelf fillers such as hyaluronic acid (HA), polylactic acid, and hydroxyapatite. Most dermal fillers apply to depressed scars, such as the atrophic rolling variant.
Acne Scars Botox Injection
Scarring occasionally occurs in areas that are subject to recurrent movement. Scars may be less noticeable when one is young. The tissues can resist movement through the flexibility and springiness of the dermis and the subcutaneous volume overlying the muscle action. However, aging develops a combination of events such as photodamage, recurrent facial habits (smoking, elocution), and loss of volume that combine to make tissues naturally unable to resist the underlying muscular forces, especially in grade 3 rolling atrophic type of scars.
Botulinum toxin has been proven effective in minimizing post-surgical scars because of its ability to decrease movement and stress around a healing wound. Botox may be used in a prophylactic method of scar minimization to aid in the best healing. Botulinum toxin may be combined with fillers synergistically. In addition to the botulinum toxin’s direct effect on reducing muscular activity, there also appears to be an inhibitory effect of botulinum toxin itself on fibroblasts, offering another potential mechanism for producing a more satisfactory outcome for problematic scar revision and lesion removal.
Acne Scars PRP Injections
PRP is used to improve the healing of ablative wounds. It supports and accelerates tissue regeneration as it contains plenty of growth factors. When injected into the dermis, these growth factors induce the proliferation of fibroblasts, promote the production of new collagen and other extracellular matrix components, stimulate stem cell migration proliferation and differentiation, and improve differentiation micro-vascularization.
Nonablative Energy-Dependent Scar Treatment
Nonablative Laser includes multiple wavelength lasers, pulsed light, and radiofrequency forms of energy delivery. Because these modalities are less aggressive, they are more useful for atrophic, rolling, or hypertrophic scars than icepicks, boxcar, or keloid scars. In addition, these therapies are more often used with darker skin types because ablative management tends to have a higher risk of pigmentary alterations. There is selective thermal stimulation of dermal collagen to increase local proliferation while the epidermis is spared.
The intense pulsed light (IPL) machines emit a wide range of wavelengths from their source that can be precisely narrowed using wavelength filters. This approach reduces the scar’s redness and stimulates collagen reorganization, thus reducing its size. A typical regimen includes up to four treatments spaced four weeks apart.
RADIOFREQUENCY SKIN TREATMENT
Radiofrequency devices use electrical energy to transfer heat to the dermis at low temperatures. These devices are not intended to resurface the skin but induce thermal damage to dermal collagen while sparing the epidermis. The thermal energy contracts and thickens collagen fibers immediately. It also induces a more prolonged wound-healing effect associated with sustained remodeling, reorientation, and the formation of new collagen bundles over later months.
Because RF energy uses an electrical current rather than a light source, it does not affect epidermal melanin; therefore, patients of all skin types, including darker skin types and those predisposed to develop post-inflammatory hyperpigmentation, may be treated with RF. Bipolar RF devices are often combined with light-based technologies, termed electro-optical synergy (ELOS). The ELOS system uses the synergistic effects of light and RF-based devices.
Minimally Ablative Energy-dependent Scars Treatment
Fractional laser treatment has bridged the ablative and non-ablative laser techniques. Fractional laser treatment is a minimally invasive treatment that delivers a laser beam divided into thousands of microscopic treatment zones that target a fraction of the skin at a time. This is analogous to a photographic image being enhanced or altered by a pixel.
While ablative laser treatments work on the epidermis (surface skin cells) and nonablative treatments work solely on dermal collagen (mid-layer of skin) only, fractional laser treatment works at both epidermal-dermal layers of the skin. Fractional lasers are primarily used to treat hypertrophic scars, boxcar scars (preferably shallow), and, less effectively, the keloid type of scars.
Ablative Lasers Scars Treatment
Many ablative skin resurfacing techniques are available at MSI, broadly grouped as mechanical, chemical, and laser abrasion. All ablative techniques result in upper to mid-dermal wounds. Dermabrasion relies on mechanical ‘cold steel’ injury, acid peels result in a ‘caustic’ injury, and lasers result in a thermal injury. All ablative resurfacing treatments work the same way.
First, the outer layers of damaged skin are stripped away. Then, as new cells form during the healing process, a smoother, tighter, younger-looking skin surface appears. Superficial or medium resurfacing is limited to the epidermis and papillary dermis. For deeper resurfacing, it can also remove the upper levels of the reticular dermis.
Ablative CO2 Laser skin resurfacing stays the gold standard for treating wrinkles and sun-damaged skin, offering unsurpassable results. The procedure effectively achieves the desired endpoint by selectively vaporizing the epidermis and a part of the dermis, thereby generating the new epidermis, collagen, and elastic tissue. Although there are various modern technologies comparable to the ablative CO2 Laser, no treatment modality to date can replace it concerning the overall improvement.
Scars will continue to improve for over six months during the wound healing phase with the new deposition of collagen, elastic fibers, and extracellular matrix. In addition, the deposition of heat has the binding effect of tissue tightening and collagen shrinkage up to 30%. This translates clinically into smoothing out superficial irregularities, including wrinkles and acne scars, and a tightening effect that improves the skin’s overall appearance.
Ablative Mechanical (dermabrasion) Acne Scars Treatment
Dermabrasion was the first significant advance in treating atrophic and traumatic scarring. Dermabrasion has many applications as a skin resurfacing tool to successfully revise scars from trauma, skin grafts, acne, and surgical incisions. The sharp edges of some acne scars cast a shadow that emphasizes the lesion’s contouring reduces these contrasts, lessening their visible impact. I can achieve the essential removal of superficial scars and a reduction of deeper scars. In addition, it may be used as an adjunct to surgical procedures such as punch elevation or grafting.
Dermabrasion is performed in an office-based procedure room. It is done under local anesthesia with the choice of sedation or general anesthesia. Regional blocks are effective and added topical anesthetics might be used to freeze the skin.
The area to be dermabrader is marked and may be divided into sections when dealing with large surface areas to ensure uniformity. A good diamond frame tip is chosen and attached to the headpiece. The skin is held taut with one hand or held by an assistant, and the dermabrader is moved across the skin with constant, gentle pressure. A back-and-forth motion is used for the diamond fraise tip, but the wire brush is moved in one direction.
The borders of the treated area are feathered to prevent any noticeable transitions. The dermabrader’s skin depth is one of the most critical factors determining the outcome. No bleeding is seen while treating the epidermis because of the lack of vasculature. Punctate bleeding is visualized when entering the papillary dermis. The papillary reticular junction is the ideal endpoint of dermabrasion and is found by increased, confluent bleeding. Dermabrasion beyond the reticular dermis can lead to significant scarring.
Immediately following the procedure, you may temporarily place saline-soaked gauze moistened with dilute epinephrine on the open wounds to achieve hemostasis. A moist environment is necessary to promote wound healing. Multiple petroleum-based products are available to keep a moist environment and prevent desiccation. The wound is cleaned daily, and the ointment is applied, as necessary. Re-epithelialization has been completed 7 to 14 days following the procedure.
Recovering from dermabrasion usually lasts 2 to 4 weeks. Patients can return to work within two weeks. Although dermabrasion is an effective skin resurfacing tool, there are associated complications that physicians and patients need to be made aware of. Abnormal scarring, including the formation of hypertrophic scars and keloids, can potentially occur if dermabrasion is performed beyond the reticular dermal layer.
It is also seen in patients with a genetic predisposition, such as collagen disorders, and those taking certain medications. I can avoid hyperpigmentation and hypopigmentation with proper patient choice and perioperative care. Patients with Fitzpatrick skin types I and II are less likely to experience pigment changes.
Patients are instructed to avoid excessive sun exposure; however, I can prescribe Hydroquinone to treat unwanted hyperpigmentation. I can treat infectious complications with antibiotics and antiviral therapy. Patients with a history of a herpes outbreak are treated prophylactically with antivirals.
Dermabrasion should be cautioned in patients with active acne who may need antibiotic treatment before undergoing the procedure. The formation of milia, small white keratin-filled cysts, may be seen the following dermabrasion and usually resolve spontaneously, but they can be treated with incision and drainage when necessary.
Various methods of derma-sanding have been added, using various carpentry tools such as drywall/plaster sanding screen or moistened silicon carbide sandpaper to manually dermabrader the skin. Its benefits include the removal of the skin surface and refined contouring of scars. It is best to treat grade 3 rolling scars and tighten the skin of an older patient with scarring.
Ablative Chemical (TCA) Scars Treatment
Chemical peeling is cost-effective, and where expensive recurrent laser technologies do not exist or are not practical, it is an excellent alternative resurfacing technique. It is a safe and effective modality in dark-skinned patients to treat post-acne scarring. I
t has also been combined with dermabrasion to increase efficacy and decrease postoperative pain and complications. As with any resurfacing procedure, many patients will develop post-inflammatory hyperpigmentation. The medium-depth peels are primarily considered 10% to 40% TCA solutions.
A variation of chemical peeling involving 60% to 100% trichloroacetic acid, termed the CROSS technique, has raised interest in treating the smaller ice pick and boxcar type scars, which have always been used and proved a challenge. This modality scars the inside of the already cylindrical scar, making it cosmetically more appealing. After 3 to 6 treatments, 90% of patients showed good (50%-70%) improvement. A similar concept has been discussed with the use of high-energy CO2 lasers.
Hair Transplant Surgery Scars Treatment
We extracted follicular units (FUE) from the beard instead of the scalp so that the texture, color, and thickness of transplanted hairs stay the same as that of surrounding beard hairs. Hair transplantation for acne scars in the beard area in males is an innovative, less time-consuming, and less expensive technique. I can perform in a single sitting without any post-procedure side effects. By this technique, one can almost achieve the patient’s expectation of the non-visibility of acne scars.
Acne Scars Subcision Surgery
Subcision is a tri-bevel needle probed under the lesion through the needle puncture, so it is not an accurate incision. This movement results in the release of papillary skin from the binding connections of the deeper tissues. It creates controlled trauma that leads to wound healing and associated added connective tissue formation in the treated location. Performing variable depths of sweeping, fanning, or lancing may be necessary to disrupt the fibrous connections. It has become a first-line treatment for many isolated, moderately bound down, atrophic scars. A combination of subcision and non-ablative Laser suggested a synergistic effect.
Acne Scars Surgical Treatment (Punch graft, elevation, and Excision)
Many scars are not amenable to pure resurfacing procedures, including boxcar scars with a white atrophic base, sharply punched out, and the ice picks scar. The icepick, boxcar, and rolling scars are often addressed by surgery such as punch excision, punch elevation, and punch replacement.
A scar “requiring a punch more significant than 3.5 mm” is repaired by elliptical. The goal is to trade a more prominent, deeper scar for a smaller, linear closure that will hopefully be less noticeable and fade with time.
Punch elevation is a variation of another punch technique, except that the scar is not discarded. The tissue cylinder is incised down to the level of the subcutaneous fat, and the scar can float up until it reaches the same level as the surrounding skin. A small piece of surgical tape initially holds the cylinder of tissue in position while the patient’s serum fixes it in place, so sutures are not required. Resurfacing can be performed 4–8 weeks later if needed.
Macro, Micro, and Nano-fat Injection Treatment of Acne Scars
Fat should be considered the best filling and volumizing agent for atrophic acne scars combined with more profound tissue destruction. When higher volumes are needed, fat injections can save costs for the patient. I can combine fat with other resurfacing techniques.
Fat is not considered adequate for individual bound down ice pick scars. However, once the scar is freed, fat may be satisfactorily injected. Fat injections can be on any tissue plane as determined by the subcision or within all three (intradermal, subdermal, and subcutaneous) tissue planes.
Only microdroplets are usually needed for intradermal or immediate subdermal placement. Often injection is best accomplished as the needle is withdrawn. The endpoint is a slight overcorrection. Although microinjecting fat and intra-lesion within the scar after subcision, Prof Moawad still recommends injecting at least a small amount underneath to volumize the area. This helps to stretch or distend some scars, making them more superficial in appearance. Fifty percent of transplanted fat should be expected to survive. Touch-up procedures at six months may be needed.
Acne Scars Treatment (Grading System)
Grading post-acne scarring has been looked at as an exercise in the morphological assessment of individual scars. This is needed so that one can plan treatment specifically for this scar. Other scenarios need similar specific treatment. A rolling scar may be filled or resurfaced, a punched-out scar grafted, elevated, or excised, a deeply atrophic scar may need a fat transfer, and hypertrophic scars may need intralesional injections.
Grade I Acne Scars Treatment
This grade 1 is all about the skin surface discoloration (erythematous, hyperpigmented, or hypopigmented) and is visible to an observer up close and from a distance. It was evident at a distance without makeup. Many women will apply concealers and thick makeup to camouflage marks and make themselves liable to secondary comedones changes by acne cosmetics.
The facial reconstruction paradigm focuses on improving the skin’s surface in this level of scarring. The resolving acne site’s first presentation may be pink or red but usually improves. Color is vital to patients because we tend to judge the health and age of an individual based partly on the evenness of their skin color. Home care, skin products, and vascular Laser are needed for erythematous scarring or marking. It is better to consider vascular lasers in a patient whose predominant scar type is erythematous.
Post-inflammatory hyperpigmentation is a very commonly seen variant. It is a black or brown residual discoloration in the location of earlier acne or other inflammatory reaction. These lesions frequently occur in patients with darker skin or those who have tan skin.
Chemical peels, lasers, or bleaching agents are usually the first-line therapies. Fading may occur but often takes a prolonged time, sometimes up to a year. Pigment-specific lasers (q-switched Nd: YAG 1064nm), intense pulsed light, and the 1,927-nm thulium fractionated Laser are most likely to succeed with pigmented scars.
Hypopigmentation is a loss of pigment in the lesion. It can range from lightning to total whitening of the skin. Often these areas do not regain the level of earlier pigmentation and only later if so. After the acne is addressed, I can consider multiple treatments for these pigmentary lesions.
Current treatment modalities include medical treatment (immune-modulators, retinoids), skin grafting, scar excision or revision, cosmetic camouflage, cosmetic tattooing, dermabrasion, chemical peels, and various forms of photo- and laser therapy. Several techniques used to treat vitiligo may also help treat specific superficial hypopigmented scarring. There have been scattered reports of re-pigmentation after manual dermabrasion.
Grade 2 Acne Scars Treatment
Grade 2 scarring is again mainly about the skin surface. It is a mild, atrophic, or hypertrophic disease, which may not be evident at a social distance (e.g., talking to someone conversationally in standard lighting) and is easily covered with makeup. Usually, this is a mild atrophic disease, but occasionally mild papular scarring will produce small lumps, especially on the nose or chin. This group is in danger of exaggerating their problem and being over-treated by physicians with traditional resurfacing procedures.
Grade 3 Acne Scars Treatment
Grade 3, or moderate disease, scarring involves moderate atrophic or hypertrophic scarring noticeable at a conversational distance. It incorporates rolling scars and superficial boxcar scarring. This level of scarring needs skin surface improvement. Volume changes with filling agents, movement-related changes with neurotoxins, particularly in the lower face and perioral area, and surgical options, including subcision.
Grade 4 Acne Scars Treatment
Grade 4 post-acne scarring is usually non-distensible and includes severe atrophic or hypertrophic scarring noticeable at conversational distance and cannot be flattened by manual skin stretching. This grading incorporates deep box scarring, ice pick scarring, deep lumps, and more severe or widespread hypertrophic scarring. This level of scarring again needs skin surface improvement and volume changes with filling agents, movement-related changes with neurotoxins, and several surgical options, including punch excision, elevation, and floating technique.
- Various treatment modalities range from topical therapies, chemical peelings, micro-needling, microdermabrasion, subcision, and autologous ⁄ non-autologous dermal fillers to energy-based technology such as fractioned ⁄ non-fractionated lasers, ablative/non-ablative lasers, pigment or vascular-specific lasers, and minor surgical procedures.
- Whatever the choice, it should be clearly understood by both physicians and patients that, at present, improvement of scarring, rather than total cure, is the goal. Any intervention or treatment aims to improve scars, not for a total cure or perfection.