Acne scarring is a treatment that we specialise in at our Sydney clinic. Acne scars can cause significant disfigurement, which in turn can have severe psychosocial implications.
Acne scars are a challenge to treat, and a multimodal approach is required to achieve the desired cosmetic result.
Cause of Acne Scarring
Acne scarring is the result of an abnormal wound healing response following cutaneous inflammation with excessive matrix degradation and atypical collagen biosynthesis. Early and definitive treatment of acne is vital to prevent acne scarring.
Acne Scarring Classification
Scar classification and subtyping can guide treatment options. Mild scarring is not obvious to the observer at 50 cm, moderate scarring is obvious at 50 cm and severe scarring is obvious at distances greater than 50 cm.
Classification: 2 categories Atrophic and Hypertrophic scarring
Atrophic are the most common type of acne scarring. Destruction and loss of collagen and elastin in the dermis, as well as atrophy in the superficial subcutaneous fat result in contraction and subsequent tethering down of the epidermis.
Atrophic scarring can be categorised into the following groups:
ICE PICK SCARS
- Less than 2mm wide, narrow, deep, sharply demarcated
- Can extend into deep dermis/sub-cutaneous tissue
- Wider at epithelial surface and taper downwards
- Resistant to most skin resurfacing options (due to their depth)
- 4 – 5 mm wide, more shallow, undulating appearance
- Rise and fall of skin surface due to fibrous anchoring of dermis to subcutis
- Requires treatment at subdermal level
- Wider at the base, does not taper
- Round to oval depressions in the skin with crisp margins
- Can be shallow [less than 0.5mm deep] or deep [more than 0.5mm deep]
These scars are raised.
As the lesion resolves, collagen is gained. The result is a firm, raised papule or plaque.
Hypertrophic scars develop within 4-8 weeks of injury with rapid growth for 6 months. They do not extend beyond the margins of the injury and are not progressive; in fact regression is a possibility after 12-18 months. Recurrence rates after revision are low.
Keloids on the other hand are progressive and extend beyond the margins of the injury/ lesion. Regression is unheard of. Keloids can develop up to several years after even minor injury. They have a high recurrence rate after revision.
Red or Pigmented Scars
The appearance of both atrophic and hypertrophic scars, are often highlighted by either erythema and/ or hyperpigmentation. This aspect of acne scarring should be addressed early as it can make a drastic difference to the overall appearance of the scarring.
Other important considerations in the management plan include:
- Acne status –active or resolved?
- Wound healing – recent Isotretinoin use?
- Other skin conditions/ risk of Koebnerization?
- Skin type and risk of pigmentary changes?
- It’s vital to have direct lighting overhead, this accentuates the scars.
- Assess type/colour /depth/location- scars on the body are less responsive than facial scars and take longer to heal as there are less pilosebaceous units from which regeneration can occur.
Factors that can influence treatment outcomes should be assessed.
- Scar distensibility – ice pick and tethered scars do not respond well to dermal fillers or skinboosters.
- Palpable fibrosis beneath scars – necessitates excision or subcision prior to other treatments.
- Keloidal or hypertrophic scars in other body areas?
- Skin colour (Fitzpatrick Skin Typing)
ACNE SCARRING TREATMENT OPTIONS
Treat with Vascular laser or BBL
PIH (Post inflammatory Hyperpigmentation)
Treatment with topical lighteners, and energy devices to treat pigmentation
Focal Treatment on Individual scars
Focal treatment to target resistant acne scars. These scars will often need multiple treatment so it’s beneficial to start with them
The idea is the cut the underlying tethering. Bevelled 25/27/18/20 G needles can be used depending on the scars to be treated.
Needle is placed in dermis with the bevel flat and then moved (ante-and retrograde) through the scar in a fanning pattern. The needle is then rotated 90 degrees and the fan repeated. Follow with pressure.
TCA Cross ie Chemical Reconstruction Of Skin Scars using high concentration (70-100%) Trichloracetic acid. A very small amount of TCA is placed in the base of the scar, a toothpick is most commonly used but other methods can also be used. The interior lining of the scar undergoes a chemical peeling process, new collagen is then formed in the scar with resultant decrease in the depth and severity of the scar.
The desired end-point on the day of treatment is a small area of “frosting” or whitening. This can be visible or up to 12 hours, after which only a bit of redness can be seen. A small scab falls off after 3-7 days. Treatment can be repeated at 4-8 week intervals. TCA Cross is the most efficacious treatment to treat deep scars safely. The procedure is very well tolerated and rarely requires any form of anaesthesia. Sun protection is essential for the first week after treatment.
Dermal Fillers are the preferred method for rolling scars. Patients can see results immediately, which they love. It’s important to use a filler with low hygroscopy and mild to moderate crosslinking. Belotero balance and RHA 1 or 2 are ideal. During placement, modified subcision is performed to release underlying tethers. Minimal bruising and swelling settles promptly. Results have great longevity due to local increase in collagen production, secondary to both trauma and dermal filler.
Certain fillers have biostimulatory effects, meaning that they stimulate the skin’s fibroblasts to produce more collagen, which is beneficial with acne scarring.
Platelet rich plasma is rich with cytokines and growth factors, which work together to regenerate and stimulate the production of new collagen. The benefit with PRP is that it is autologous with minimal risk of allergy/ adverse outcomes.
Skinboosters are very popular with patients with atrophic acne scarring. They can be used in the area of the scarring to make the skin appear more “plump” and more like the less scarred areas. The skin booster product also stimulated collagen in the area.
Skinbooster can be injected by hand or by using a beauty gun, where the depth can be set precisely.
Full Face Treatments for Acne Scarring
Full Field Ablation Resurfacing
Full field ablative laser (ie the whole surface area of the skin is treated, unlike a fractionated laser. Laser types are 2940 nm Er:Yag (Erbium laser) or 10600nm Co2 lasers. This is an effective treatment option for acne scarring. Downtime in the order of 5 days to 2 weeks is standard depending on depth of treatment. Potential adverse effects including: persistent erythema, infection, post-inflammatory hyperpigmentation, scarring and rarely hypopigmentation should be considered.
Fractional Ablative laser
Fractionated ablative laser is a successful treatment for acne scarring. Erbium or C)2 laser may be used. Fractionated mode can achieve a greater depth than full field resurfacing, but only treats approximately 10-20% of the skin surface area compare with full field resurfacing. Recovery period are quicker, with approximately 3-4 days healing time. Optimal results will require repeat procedures.
Fractional Non-Ablative laser
Fractionated non-ablative: 1540 or 1550 nm non-ablative lasers have recovery times of only 0-3 days, however multiple treatments are required to achieve satisfactory results.
Fractional RF aka Microneedling RF (Radiofrequency)
Microneedle bipolar RF and fractional bipolar RF has been proven beneficial with an improvement of 25-75% after 3-4 treatments. It works by passing a current through the dermis which produces small thermal wounds, these in turn, stimulate collagen production. Downtime is quite minimal
Superficial – SCA / glycolic / lactic / Jessner (epidermal peel)
Medium depth – Jessner plus 10 – 25%? TCA (to level of papillary dermis)
Deep – phenol containing (to level of reticular dermis) [risk of cardiac toxicity/nerve damage]
- Dermabrasion -deeper than microdermabrasion with a high risk for postoperative scarring/ pigmentary changes and milia formation
- Skin needling
Treatments for Hypertrophic Scarring
- Intralesional steroid injections, Adverse effects of intra-lesional steroids include: skin atrophy and telangiectasia. – 0.1 – 0.2 ml/cm maximum 1 – 2ml every 4-8 weeks
- Kenacort A10 (Triamcinolone acetonide) 10mg/ml for hypertrophic scars
- Kenacort A40 (Triamcinolone acetonide) 40mg/ml for keloidal scars
- Cryotherapy – 10-20 freeze/thaw cycles
- Fractionated non-ablative laser
- RF microneedling
- Erbium laser
- 5FU 50 mg/ml
- Interferon alpha2b
- Silicone gel sheeting (24hrs for 1 – 12 months)
Please call the clinic and book an appointment for assessment of your acne scarring