Introduction to Acne Scars
Acne is a common skin disease that generally results in scarring. Acne Scars secondary to acne can lead to physical disfigurement, and the psychosocial impact can be profound.
Although various therapies may reduce the prominence of acne scars, no cure obliterates acne scars. A multimodality approach to Acne scar treatment is usually necessary to achieve the best cosmetic results. The selection of a therapy method is based upon factors such as the type and degree of acne scarring, patient preference, side effects, cost, and treatment availability.
Treatment Principles
Medical therapies for acne target one or more of four key factors that promote the development of acne lesions: follicular hyperproliferation and abnormal desquamation, increased sebum production, Cutibacterium (formerly Propionibacterium) acnes proliferation, and inflammation.
Chemical peels For Acne scars
Chemical peels can be effective treatments for acne scars. As with laser resurfacing, injury to the skin caused by chemical peels can stimulate a wound healing response with collagen remodeling. Chemical peels are classified into superficial, medium-depth, and deep chemical peels according to skin injury depth.
Superficial chemical peels, such as salicylic acid, lactic acid, glycolic acid, Jessner solution, and 10% to 25% trichloroacetic acid affect only the epidermis. Medium depth chemical peels, such as combination treatment with Jessner solution and 35% to 50% trichloroacetic acid, injure the skin to the papillary dermis level.
Dermabrasion
Although acne scars were previously one of the most common indications for dermabrasion, the use of dermabrasion for acne scars has fallen significantly since the rise in the use of laser resurfacing therapy. However, in skilled hands, dermabrasion can be highly effective for severe acne scarring.
Dermabrasion involves using tools (e.g., high-speed brush, diamond cylinder, frail, or silicon carbide sandpaper) to remove the epidermis or epidermis and part of the dermis. An advantage of the procedure is that it allows the clinician to etch scar edges precisely without thermal injury. However, dermabrasion is highly operator-dependent, requires meticulous intraoperative assistance, and has the potential for severe postoperative scarring, pigmentation, and milia formation.
Skin Needling
Skin needling procedures can improve acne scars. Like fractional lasers, needling procedures induce small columns of damage in the epidermis and dermis, leaving intervening skin untouched. A needling device typically consists of a circumferentially studded cylinder with 1 to 2.5 mm long needles. The device is rolled over the skin’s surface to form numerous perforations in the epidermis and dermis to stimulate neo collagenases. Advantages of skin needling include low cost, a relatively short recovery period (two to three days), and a shallow risk for post inflammatory hyperpigmentation.
Traditional ablative laser resurfacing
Traditional ablative laser resurfacing involves using a 2940 nm erbium: yttrium aluminum garnet (Er: YAG) laser or 10,600 nm carbon dioxide (CO2 ) laser. These lasers target water in the skin, resulting in the epidermis and dermis ablation in exact increments. The thermal injury caused by the laser promotes collagen contraction, collagen remodeling, and skin tightening, effects that can result in improvement in the appearance of scars.
Generalized atrophic facial for Acne scars
Frequently, patients present to treat facial acne scars have multiple scars. This presentation is best managed with a field approach to treatment. Patients who require only a few specific scars can be managed with some of the same treatments.
Because no single treatment completely removes acne scars, a multimodality approach to generalized facial acne scars is most likely to provide the best treatment results. Our ideal result-focused approach to generalized atrophic facial acne scars can be summarized in three key steps:
- Step 1: An initial treatment phase consists of erythema treatment within scars (if present) and focal treatments to target individual scars that are likely to be resistant to collagen remodeling procedures.
- Step 2: A collagen remodeling procedure (the gold standard is full-face resurfacing with a traditional ablative laser)
- Step 3: Additional treatments designed to address resistant scars and augment the results of the collagen remodeling procedure (e.g., injectable soft tissue fillers, additional nonablative or ablative fractional laser treatments)
Pulsed-dye laser
Pulsed-dye laser therapy improves erythema in scars by targeting oxyhemoglobin within vascular structures in the skin. Successful treatment of acne scar erythema with a pulsed-dye laser usually requires three to four or more treatments given at approximately one-month intervals.
Focal treatment of scar
Deep ice pick scars, and deep boxcar scars may respond poorly to laser resurfacing and other collagen remodeling procedures. Treatment of prominent scars of these types with one of the modalities below may improve the final results of treatment.
CROSS technique (Chemical reconstruction of skin scars technique)
Indication: Ice pick and narrow boxcar scars. Description: A high-strength trichloroacetic acid (TCA) peel solution (100%) is placed directly in the base of scars to ablate the epithelial wall and to promote dermal remodeling.