Treatment of acne scars

Scars are a visible and often also permanent remnant of acne, which even a relatively mild course may have consequences in the form of scars. It is also impossible to predict in which Patients acne will leave this unwanted trace, and in which not. Scarring may result from inflammatory changes or the Patient's actions.

Acne scars are very common and occur in one in five people who have had acne. Everyone’s skin heals differently and whether a scar will form depends largely on our genetic predisposition. Other factors that may contribute to acne scarring are the depth of acne lesion in the skin, extrusion of the lesion, color of the skin, smoking, and finally, acne that was treated incorrectly or too late. The more inflamed the acne lesions are, the more likely it is that a scar will form. This is one of the reasons why it is worth treating acne as soon as possible, preferably under the care of a dermatologist specialist.

There are two main types of acne scars, defined by tissue responses to inflammation. Hypertrophic scars – caused by increased tissue formation and atrophic scars – caused by tissue loss.

On this website you will find information on the different types of scars that develop after acne, what causes them and how to improve their appearance with properly selected treatment. In Zakrzewscy Clinic we have many methods which effectively reduce existing acne scars.

Atrophic acne scars are more common than scarring and hypertrophic scars. Atrophic acne scars include:

• Ice pick scars

Ice pick scars are a common type of scar that can occur as a result of the acne healing process. They appear as small, sharp indentations that are wider on the skin surface and narrow to a point as they extend down into the skin. In cross-section, they take on a V-shape. They are not always the same size as the original acne lesion from which they formed, as the size depends on how the skin heals. Ice pick scars are more common in areas of the face where the skin is thinner, such as the forehead and upper cheeks, and are one of the more difficult types of scars to treat because they are too deep to be treated with conventional resurfacing methods.

• Rolling scars

Rolling scars (cylindrical in shape) are characterized by fibers that bind the dermis to the subcutaneous tissue. They are usually 4 to 5 mm wide. These scars give the skin a cylindrical or wavy shape (they resemble an M-shape in cross-section). Successful treatment of rolling scars involves eliminating the subcutaneous bonds. This type of scar is more common in areas of the face where the skin is thicker, such as the lower cheeks and jaw.

• Boxcar scars

Boxcar scars are a type of oval or round scar with distinct vertical edges. These scars are usually wider on the skin’s surface than ice pick scars and are not V-shaped converging. Instead, they may be visualized in cross-section in a U-shape, with a wide base. Boxcar scars can be shallow or deep. They form more often in areas of the face where the skin is thicker, such as the lower cheeks and the jaw area.

Treatment of atrophic acne scars

The goal of acne scar treatment is to reduce the visible changes and make the skin look more acceptable to the Patient. Treatment may be surgical or non-surgical.

Surgical techniques

There are 3 basic surgical techniques used to treat atrophic acne scars. Excision with or without grafting, lifting and subcision.

• Scar excision is the technique used for diffuse, single ice pick scars. Each individual scar can be removed by excision with a biopsy punch. The scar is removed to the level of subcutaneous tissue. The resulting hole in the skin is then sutured. The scar excision procedure can be performed with or without a graft. This type of therapy can be used for ice pick scars and narrow, deep boxcar scars.
• Scar lifting involves a partially lateral circular excision of the scar borders, leaving deep portions of the scar adjacent to the fatty tissue. Once the edges of the scar are isolated from the surrounding skin, the scar is lifted to slightly raise it above the surrounding tissue. As the tissue heals, it retracts and becomes level with the facial skin surface. There is no risk of skin color or texture mismatch here. Lifting should be used in boxcar type scars with sharp edges and good looking bases.
• Subcision or subcutaneous incision can be used to treat rolling or concave scars. This technique releases the fibers that bind the scar to the underlying tissues, which is the cause of "pulling" the scar below the skin surface. During the scar subcision procedure, a sharp needle is inserted under the skin, with the blade parallel to the skin surface, and then moved in a sweeping motion to cut the underlying fibers. Additional improvement can be achieved when the subcision technique is combined with Alma Pixel CO2 or DPP Frax fractional laser treatment and Dermapen treatment.
• Filling of atrophic scars can be done using various types of fillers or autologous fat tissue. Crosslinked hyaluronic acid can be used to fill certain types of superficial and deep scars, but this technique is not applicable to ice pick and fibrotic scars. Using hyaluronic acid injections, a temporary improvement is achieved i.e. for about 6-12 months, depending on the material chosen. Hyaluronic acid injections should be repeated to maintain a good effect.

Non-surgical techniques

• Resurfacing techniques aim to destroy the old epidermis, recovering the skin with epithelium and remodeling collagen fibers. These techniques include chemical peelings, dermabrasion, resurfacing with the Alma Pixel CO2 fractional laser or the Discovery Pico Plus picosecond laser, and microneedling with the Dermapen 4.0 device. These techniques are the best treatment option when scar treatment covers a larger area. Sometimes the treatment needs to be applied sequentially, e.g. treatment of single larger scars should precede the treatment of lesions on a wider area. To enhance and maintain the effect of scar treatment and prevent discoloration, it is worthwhile to include in the therapy topical retinoids, such as Wrinkle Texture Repair by ZO Skin Health.
• Chemical peeling is a popular treatment for atrophic acne scars. Chemical peelings that reach a medium depth are most useful for smoothing small scars. This treatment should not be used to treat ice pick scars or deep fibrotic scars. Repeated exfoliation with Jessner’s solution, TCA up to 35 percent or glycolic acid may improve mild scars. For deep ice pick and boxcar scars, the CrossTCA technique, which involves focal application of highly concentrated TCA (80 to 100 percent concentration) administered with a sharp blade to the scar, has shown good results.
• Microneedling is a minimally invasive dermatological procedure, also known as percutaneous collagen induction (PIC), in which thousands of microneedles are inserted into a Dermapen 4.0 device and moved across the skin’s surface. This procedure was originally used for cosmetic purposes – a special roller with needles was used to stimulate the production of new collagen and elastin. Nowadays, the needle rollers are no longer used, and micropuncture with Dermapen 4.0 is used to treat many dermatological conditions, including acne scars. The mechanism of micropuncture action is based on a precisely controlled performance of many microscopic wounds in the epidermis and in the papillary layer of the skin, which is intended to initiate the wound healing reaction. Microneedling causes microscopic inflammation, initiating a platelet response, which in turn releases platelet-derived growth factors and activates fibroblasts to produce new collagen fibers.
• Laser therapies are an increasingly common method used to treat dermatological problems, including scars. To reshape scar tissue and reduce erythema and post-inflammatory hyperpigmentation of PIH, we most commonly use the Discovery Pico Plus Fractional Non-ablative Frax Laser and the Alma Pixel CO2 Ablative Laser. The choice of the optimal laser system and parameters depends on the scar characteristics.

Alma Pixel Co2 Ablative Laser – emitting high energy density, with very short pulses, vaporizes target tissues with limited damage to the surrounding skin. Improved skin texture and scar appearance are the result of collagen remodeling and smoothing of the skin surface. Using the CO2 laser, improvements of approximately 50 to 80 percent can be achieved for atrophic scars. With this laser, the epidermis and papillary layer of the skin are vaporized to a depth of 20 to 60 micrometers. Ablative resurfacing may cause side effects such as erythema, swelling or serous leakage. However, these are temporary and disappear within a few days. After Alma Pixel CO2 laser treatment, the treatment area is irradiated with LED Dermalux TRI-Wave MD lamp, which significantly accelerates the healing process.

Discovery Pico Plus Non-Ablative Laser with Frax head – treatments for acne scars with DPP FRAX laser is designed to destroy tissue from the scar area and initiate remodeling and collagen synthesis. The 1064 nm Frax head has the ability to focus the beam into the dermis, minimizing the risk of damage to the skin surface. As a result of the focused beam, so-called vacuoles are formed in the epidermis and dermis, but laser-induced optical breakdown (so-called LIOB) occurs only in the dermis, where changes involving the breakdown of old collagen fibers occur as a result of the laser. These structural changes in collagen fibers stimulate the extracellular connective tissue matrix to remodel. Since the main building block of the scar is the connective tissue, the desired remodeling effect occurs. Due to the fact that LIOB occurs only within the dermis, the skin surface remains intact. Thus, skin healing is accelerated, side effects are minimized and the risk of post-inflammatory hyperpigmentation (PIH) is negligible.

Hypertrophic scars and scarring occur at the site of skin tissue damage, where the skin’s natural repair processes have become too intensive, leading to excessive collagen deposition and decreased collagenase activity. Hypertrophic scars, palpable under the finger, are usually pink in color, convex and hard with high collagen content. They may cause itching. They occur mainly on the trunk; upper and mid back, sternum and collarbone area, shoulders, and deltoid muscles.

Scarring (keloid scars) form reddish-purple lumps and nodules that proliferate beyond the borders of the original skin injury. These scars may appear long after the original skin damage or even without skin damage. Keloids are more common in people with darker skin tones. They can cause itching and often pain. They occur mainly on the trunk; upper and mid back, sternum and collarbone area, shoulders, deltoid muscles.

Treatment of keloids and hypertrophic scars is aimed at flattening them, i.e., reducing the scar height so that the skin surface is even.

• Corticosteroid injections are a very common treatment for hypertrophic scars and scarring. It involves injecting a corticosteroid directly into the hardened tissue of the keloid using a thin needle. Softening of the scar and relief of itching occurs just a few days after the first injection, while subsequent treatments cause the scar to begin to fade and shrink. Several injections are recommended (depending on the severity of scar) at intervals of 4 to 6 weeks.
• Compression therapy involves applying a compression dressing to a healing wound to reduce or prevent the formation of a hypertrophic scar or scar tissue. Achieving good results from therapy requires the use of a compression dressing over a long period of time.
• DERMALUX TRI-WAVE MD LED Phototherapy is usually considered as a complementary therapy to other scar treatment techniques. It consists of irradiating scars with therapeutic LED light without the negative effects of ultraviolet radiation. Wavelengths used for scar treatment are those that have the ability to stimulate skin regeneration by increasing blood circulation and cell metabolism. Moreover, phototherapy stimulates fibroblasts to synthesize collagen, elastin, and glycoproteins, the production of which is necessary to improve the appearance of existing scars. This treatment has an anti-inflammatory effect and evens out skin tone.

Perifollicular papular scars are another type of acne scars. These are protruding, firm, hard acne lesions above the skin level, most commonly found on the back, arms and less often on the chest and virtually absent on the face. They form as a result of loss of the protein elastin. These scars are round or oval, slightly white, and protrude above healthy skin. They resemble closed blackheads and are often confused with them. Piercing the top with a pointed scalpel distinguishes them from blackheads because the contents do not come out.

Treatment for this type of scar consists of two stages, as is often the case with other acne scars. In the first stage, treatments aim to reduce the scar height so that the skin surface resumes being flat. The second stage treatments for perifollicular papular scars aim to reduce the discoloration of the skin around the scar.

The first stage of treatment involves corticosteroid injections. This involves directly injecting the hard scar tissue with a thin needle to soften the fibrous structure of the scar and bring it down in height. This stage usually requires several injections at intervals of 4 to 6 weeks. It is then that the best treatment results are achieved. The second stage of treatment involves the above described Dermapen 4.0 micropuncture treatments and laser therapy, similar to the treatment of other types of acne scars.

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