Managing Acne Scarring
Post-acne scarring is a very distressing and difficult problem for physicians and patients alike. Recently, newer techniques and modifications to older ones may make this problem more manageable. Patients suffer from a variety of post-acne scars, including superficial macules, dermal trough scars, ice pick scars, multi-channeled fistulous tracts and subcutaneous atrophy. This article will look primarily at treatment options for atrophic scars caused by acne.
The wide variety of treatment methods for post-acne scarring includes resurfacing tools such as CO2 and erbium infrared lasers, dermasanding, and the newer treatments of fractional photothermolysis and plasma skin resurfacing.
Dermal and subcutaneous augmentation with autologous and non-autologous tissue augmentation and the advent of tissue undermining (subcision) have greatly improved treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well.
“Acne scar patients vary, and the same patient usually has many different types of scars,” says Gregory Goodman, M.B.B.S., F.A.C.D., Director of the Mohs Micrographic Surgery Unit, Head of Surgery at Skin & Cancer Foundation of Victoria, and a Senior Lecturer at Monash University, Victoria, Australia.
“You have to individualize the therapy, matching the treatment techniques to the scars. You have to possess the skills and the tools to specifically address each of those scars. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary.”
Classifying Acne Scars
According to Dr. Goodman, several attempts have been made to classify scars — some were too simplistic to be useful and others too complex and cumbersome to use in practice.
For treatment purposes, scars can be classified as macular, atrophic and hypertrophic.
Macular scars are generally scars that are at skin level and are primarily discolorations of the skin.
Atrophic scars are depressed scars such as boxcar, ice pick scars and tunnel scars.
Hypertrophic scars are elevated scars and include papular, bridge and dystrophic scars.
Treating Flat Macular Scars
Flat macular acne scarring can be pigmented or it can be white or it can be erythematous.
“If you have pigmented scars, the best way to treat these is with time, patience, sun avoidance, and bleaching preparations,” says Dr. Goodman. “Also, some light peels, and maybe nowadays you might do fractional photothermolysis or something similar. If a person has hyperpigmentation, lasers that treat pigmented lesions have variable success.”
Treating Atrophic Scars
There is a wide range of treatment options available for trophic scars, but physicians must match the treatment approach to the specific scars, the patient’s skin type and the patient’s age, gender and tolerance for discomfort or temporary changes in appearance.
Infrared Laser Resurfacing
According to Dr. Goodman, laser resurfacing is still the gold standard technique for widespread scarring. It’s best for mildly atrophic rolling scars, although it works reasonably well for slightly deeper scars. He cautions that this treatment is not good for hypertrophic, ice pick scars or deep dermal scars. Nor will it be useful for anything that’s sharply punched out.
“The CO2 and the erbium laser are the two most commonly used lasers for skin resurfacing. However, the CO2 laser creates a great deal of thermal damage to the skin, requiring more downtime and healing,” explains Dr. Goodman. “The modulated erbium laser offers a better alternative as it creates less equivalent thermal damage left in the skin.”
Laser resurfacing works very well on both men and women, but men are not likely to wear makeup to cover the redness during healing.
“You need to discuss this with your male patients. Males actually do very well from resurfacing,” says Dr. Goodman. “They’re a very low risk group, far less risk than a female, but it is hard to get them through the actual treatment.”
Manual dermasanding technique has made a bit of a comeback. Basically, you use a piece of sandpaper to sand the scarring down. It can be an effective approach to certain types of scars.
Plasma skin regeneration technique is only for mild scarring and involves radiofrequency-induced bombardment of the skin with high-energy plasma. The skin absorbs the energy non-specifically and sheds the dermis.
Collagen Induction Therapy
Collagen induction therapy, also called skin rolling, uses a roller embedded with dozens of thin needles that is literally rolled over the skin surface. The needles penetrate deeply enough and are dense enough to induce the skin to produce collagen. “This is quite painful to do without general anesthetic, but if you anesthetize a patient properly, the procedure can be nearly as effective as laser resurfacing without the side effects,” says Dr. Goodman. “You need to treat the area with topical anti-oxidants while the holes heal, but I have treated several patients with good results. It seems to be a very safe process.”
Fraxel Laser Therapy
Fractional photothermolysis works on the same fundamental principle as the skin rolling technique except that you use a very controlled light energy burst to punch the holes, not a metal needle. The idea is to cause sufficient damage to the skin to induce the formation of collagen, without inflicting so much damage that you permanently harm the skin.
“You really need to punch holes fairly deeply with acne scarring, but it seems to be valid,” explains Dr. Goodman. “The principle of this obviously is to punch microthermal zones into the skin leaving gaps between for rapid healing of the epidermis, and what you’re doing in the dermis is damaging it — again, that non-specific collagen reaction with limited downtime. We’ve done a few patients with Fraxel, and I think it works pretty well, too.”
The Fraxel laser was approved earlier this year to treat acne scars and surgical scars.
Non-ablative resurfacing can be effective for mild atrophic scars. This therapy works on the principle of heating the dermis sufficiently to cause injury while avoiding damage to the epidermis. There are a number of devices available, including Thermage (ThermaCool), SmoothBeam (1450 nm), CoolTouch (1320 nm), erbium glass (1540 nm) lasers and many others. “I don’t think it really matters which of these devices you select to use,” says Dr. Goodman. “They all function in essentially the same way, and you should select the device that you are most comfortable using.”
According to Dr. Goodman, these devices can be useful for augmenting other procedures to improve results or increase the longevity of your results.
“We use our SmoothBeam to augment other procedures, and it does seem to do that,” he explains. “It’s been shown to augment the effects of procedures like subcision, but also augments other procedures as well.”
Subcision is a very effective technique for correcting atrophic scars. Essentially, the physician inserts a needle and sweeps it back and forth repeatedly to free the skin from the underlying scar tissue. “Basically any instrument will do, but usually we use a NoKor. You can use really small needles, such as 25 or 26 gauge for small scars to get up high in the dermis,” says Dr. Goodman. “You want to get a little bit of a hematoma, which will produce the necessary collagen. And this seems to give a lot longer correction than other collagen induction therapies.”
Patients tolerate the procedure well. Sometimes the procedure causes the treated area to initially rise above the level of the surrounding skin, but it almost always settles back down over time. “You can do that anywhere, but be careful on the temple not to hit the temporal branch of the facial nerve,” warns Dr. Goodman. “Subcision can also augment other procedures, such as laser resurfacing or skin rolling. It can be combined with dermal augmentation agents.
For example, if you’re using a filler, for example, such as Restylane, just do a little subcision before you inject the filler agent, and that helps you sometimes when the scar is tending to pincushion a bit.”
Punch techniques are very effective for deep boxcar and ice pick scars. There are three basic punch techniques:
1. punch excision
2. punch elevation
3. punch grafting.
“I love treating patients with deep scars with these techniques because we always get good results,” says Dr. Goodman. “The patients tolerate the procedure very well and the results are often very dramatic.”
Punch excision is exactly what it sounds like. You essentially punch out a core from the scar using the appropriate size punch and then suture it closed.
Punch elevation is a technique in which the punched out core is not removed but allowed to float up to the level of the skin. The immediate effect of a punch elevation is that it comes up flush with the skin. “It takes about five minutes to punch elevate 20 scars — it’s pretty quick, pretty simple,” explains Dr. Goodman. “You just have to have an array of straight-walled punches, so you might need to buy some intermediate sizes, 1 mm, 1.25 mm, 1.5 mm, 2 mm, 2.5 mm, etc.”
“Once you do it, you just put Micropore Skintone or Steeri strips over the top, and the patient goes home and doesn’t touch it, and returns the next week to take it off, very gingerly,” says Dr. Goodman. “Just be careful when you remove the Steeri strips. It may be useful to use a softening agent, such as Vaseline on the area first before removing the micropore. You can’t punch elevate two scars right next to each other, because they fall into each other, so it’s important to do them in separate sessions.”
Punch grafting involves punching out the scar and replacing the removed core with a core taken from another area, usually from behind the ear.
I’ll utilize punch techniques often before I’m going to resurface the patient. So if I have a patient with punched out holes in his face, I’ll schedule him for resurfacing, then I’ll do the punch technique before I resurface — a series of punch elevations or punch grafts, followed by resurfacing several weeks later,” he explains.
Dr. Goodman does warn that you use caution with these punch techniques because you end up transgressing old cysts and old tracks, reactivating previous problems, and getting what looks like an infection. “It’s not an infection; it’s just the cyst trying to exteriorize itself. And the easiest point to exteriorize itself is through the wound that you just created,” he says. “So just be aware of it, put patients on pre-operative antibiotics to suppress them a bit, and they’ll do okay.”
According to Dr. Goodman, fat transfer is a fantastic for acne scarring.
“The patient’s own fat provides an abundant and usually long-lasting source of material to inject under the skin to lift the scars. The only people who it’s difficult to harvest fat from are really thin males,” he explains. “In those cases, you put them on a weight-gain diet and have them come back when they’re 5 or 6 pounds heavier.
The patients are amazingly compliant patients because they want their scars treated. Keep some of the fat in reserve in the freezer. Three months later when these patients have lost their weight, their face will have shrunken a bit, so you can augment their face again with the reserved fat.” He cautions against trying to over-correct in one session and to just accept that you have to do a multi-stage procedure.
According to Dr. Goodman, fat transfer can be done with local or general anesthesia, and it can be combined with other procedures with very little downtime. When treating acne scars with fat transfers, Dr. Goodman explains, “I don’t centrifuge the fat that I use, I just relocate it into 1-ml syringes for injection. You use really small doses of fat. You can’t inject too much because you’ll end up with lumpy blobs of fat. The best approach is multiple small amounts.Using a 1-ml syringe, you will probably try 30 to 40 placements to deliver the fat where you want it.”
You can use both permanent fillers or temporary fillers for treating acne scarring. Fillers are best used for shallow, saucer-shaped acne scars, and these filler agents include Restylane, Cosmoderm, Cymetra, Fascian, Artecoll and bovine collagen.
“I am not a big fan of fillers because each one has its own pitfalls,” says Dr. Goodman. “Also, any change in the patient’s face due to weight fluctuations will always cause problems with any filler.”
Hyaluronans are relatively new to the United States. They promise safety and are probably a very predictable augmentation.
With the multitude of treatments to choose from in treating a patient’s acne scars, it’s important to determine the type of scars and then determine the best option. Each patient requires an individualized treatment plan, but with all the great results we are seeing there’s no reason patients should have to live with their acne scars for life.
Other Treatment Options
Polylactic acid. This works pretty well and does last fairly long. It thickens tissue, and it has some contraction ability, but Dr. Goodman cautions, the number of nodules, no matter how deeply you place this filler agent, may haunt you.
Hyaluronans. Keep an eye out for Sub-Q, which is going to be an interesting compound for deep augmentation.
Focal TCA peeling. While full-face trichloroacetic acid (TCA) peeling is often used to address mild acne scarring, focal TCA peeling (also called the TCA CROSS Method) can be used on pitted scars such as ice pick scars to achieve good results on scars up to 4 mm. During treatment, a highly concentrated trichloroacetic acid is introduced inside the scar, stimulating collagen production that, over multiple sessions, causes the scar to rise and close.
Suture lifting. Suture lifting involves pulling the skin by a small incision at the back of the ear or at the temporal hairline. Threads are inserted through the incision and you pull back the facial skin and tie the threads. This procedure repositions scarring from into the mid-face, and then you can resurface or do fat transfers. This is a good option for patients who have sagging skin and acne scarring.
Silicone and CO2 laser skin resurfacing. When patients have a mixture of types of scars, combination therapy may be best. CO2 laser resurfacing works well on acne scarring with superficial skin irregularities, while silicone microdroplet augmentation works well on atrophic scars. When used concurrently, they stimulate collagen formation in the deeper portions of the dermis because of the silicone and in the upper portions because of the laser.
An Option for Difficult–to-Treat Scars
By Tina Alster, M.D.
Although it’s not a treatment I routinely use for acne scars, I have successfully treated a handful of acne scarred individuals with Sculptra injections. I typically reserve this treatment option for patients with atrophic scars that have proved recalcitrant to other treatments such as ablative/nonablative lasers, collagen/hyaluronic acid/other fillers.
Because Sculptra requires deep dermal placement, I have observed that the scars that are most amenable to treatment are those that clinically appear as skin depressions without sharp or ice-pick borders. The patients whom I have treated with Sculptra are very happy and show prolonged results (more than 1 to 2 years) after one or two sessions at 2- to 3-month intervals.