Flawless skin free of disfiguring acne scars is on top of our clients' wish list - right along with wrinkle-free skin. Acne, the beauty scourge that afflicts 90% of adolescents, persists in about 12-14% of the adult population. While we love saying that beauty is in the eye of the beholder, some acne sufferers are so bothered psychologically that it affects their social and personal lives. It is so prevalent and frustrating that a number of post inflammatory hyperpigmentation (PIH) and scar sufferers resort to old wives tales remedies, ineffective over-the-counter medicine and DIY natural treatments researched from Youtube and Facebook - oftentimes worsening the condition and even causing irritation, allergic reactions and superficial burns.
What Acne Is
Acne starts out as clogged sebaceous or oil glands usually found on the face, chest and back. The severity varies and can be affected by hormonal surges, and presence of bacteria. These reactions lead up to pus (abscess) formation and follicular rupture which triggers the healing process. Wound healing is complicated and involves 3 main processes: inflammation, granulation tissue formation and matrix remodelling. Acne lesions or pimples can be classified as:
- comedones (whiteheads and blackheads) - mild
- papules - moderate
- pustules - moderate
- nodules -severe
- cysts -severe
- scars -severe
The inflammation can lead to destruction of follicles and uneven healing. The scar develops from the point of injury or rupture and collagen formation may cause it to hypertropy (raised) while others atrophy (pitted, sunken, can be flattened by stretching the skin). Various types of scars result from acne flare-ups and some treatments are more effective than others. Strictly speaking, the redness or hyperpigmentation that results after pimples heal are not scars. But these are unsightly and require treatment if they do not fade.
The statistics are staggering. About 95% of acne patients develop scars and 30% of these are classified as moderate-severe scarring. Atrophic or flat scars are the most common (90%) while hypertrophic or raised scars are less frequent. Atrophic acne scars are classified according to shape and depth:
1. Ice-pick (pinpoint opening but deep; V-shaped)
2. Rolling (shallower than box car; crater like shape; edges usually not well-defined and "U" shaped;
makes up 70% of all atrophic scars)
3. Boxcar (rectangular or squarish, well-defined edges)
Hypertrophic scars result from the healing process that has gone on overdrive, There is overproduction of collagen and fibroblast in the area so it becomes lumpy and raised, often with irregular borders. These may be skin-toned or colored.
Care and treatment depends of the severity of the lesion and the appearance of the scar. It is best to treat the lesion according to the most likely causes such as clogged pores, dermal inflammation, hormonal imbalance/androgenization, bacterial infection and increased oil secretion. Scar formation is also a product of genetics and the person's own reaction to scar tissue formation.
Treating scars go hand in hand with controlling acne flare-up by using topical Retinoids and Azelaic acid together with topical and systemic antibiotics containing clindamycin, erhthromycin (with or without zinc) and tetracycline. Hormonal therapy with contraceptives (e.g. Diane) and antiandrogens like ketoconazole and spironolactone can be given. Metformin is given to women suffering from acne caused by PCOS (polycystic ovarian syndrome). Retinoids and silicone gel are effective in preventing hypertrophic scar formation.
The truth is,while very deep-set scars may not respond to mild non-surgical treatments, much can be done to make the scars less noticeable or diminished to the point where skillfully applied make-up can make skin look blemish and scar-free.
Some effective treatments to choose from are:
- Chemical Peels
- Fillers (e.g.Bellafill)
- Intralesional Steroid Therapy
- Punch or Elliptical Excision/Elevation, Subcision and other Surgeries including grafting
- Combinaiton Therapy
- Adjunct Therapy and topicals (more for cosmetic benefits)
The modality is chosen based on type of scar, reaction of the body to scar tissue formation and skin color. We use the Fitzpatrick skin phototype/scale to help in determining which chemical or laser therapy to use because dark-skinned people have a greater tendency to form hypertrophic scars and keloids so deep peels are not used. Those from Fitzpatrick Type IV*- VI* can react badly to deep peels and agressive photo/laser facials resulting to hypopigmentation or hyperpigmentation.
- Fitzpatrick Type I ivory/very fair (e.g. Emma Sone, Prince Henry),
- Fitzpatrick Type II beige/fair (e.g. Jennifer Aniston and Orientals like Lucy Liu, Brad Pitt),
- Fitzpatrick Type III light brown/honey or gold toned or light olive (e.g. Sandra Bullock, Matthew McConaughey),
- Fitzpatrick Type IV medium brown (e.g. Eva Mendez, Taylor Lautner)
- Fitzpatrick Type V dark brown/radiant bronze (e.g. Beyonce, Barack Obama)
*Peels or lasers like IPL can give you hypo or hyperpigmenation
- Fitzpatrick Type VI very dark to black (e.g. Naomi Campbell, Kanye West)
*Peels or lasers like IPL can give you hypo or hyperpigmenation
If you belong to either Fitzpatrick V or VI Types, ask your doctor what other options (such as microneedling) can be used in place of deep peels and lasers.
Atrophic Scars (Scars that flatten when stretched)
At Juvly, we use SkinMedica Illuminize, Vitalize, Rejuvenize, Rejuvenate, Zo Health Peel and the Obagi Blue Radiance Peels. These peels, ranging from mild to moderate are great for exfoliation and are known to diminish wrinkles and discoloration. It helps minimize the appearance of scars, smoothens texture and reveals glowing, even-colored, supple skin.
SkinMedica Illuminize is a non-invasive peel made of mandelic and malic acid (both alpha hydroxy acids), salicylic acid, resorcinol and phytic acid. It is safe for Fitzpatrick Skin Types I-IV but peeling is too gentle for deeper scars. On the other hand, SkinMedica Vitalize made of retinoic acid, resorcinaol, lactic acid and salicylic acid is used for anti-aging, safe for all skin types and effective for melasma & acne-prone skin. The SkinMedica Rejuvenate Peel with emollients like Isoceteth 20 and panthenol, in addition to the peeling ingredients is our strongest peel (that can be conducted without general anesthesia) and is perfect for more defined wrinkles and acne scars. Hyperpigmentation due to various reasons, including acne and melasma can be diminished significantly by using rhe Obagi System. The Obagi Blue Peel or Radiance Peel, affecting the dermis, has TCA as the active ingredient and is considered light-medium strength.
Chemical peels involve controlled destruction of the outer and damaged layers of the skin which encourages growth of new skin and more uniform collagen formaiton. Mild-Moderate peels may work for macular scars but deeper ones like ice-pick scars, rolling scars and box-type scars only work with deeper peels. Deep peels can be done under anesthesia and should be carefully monitored especially in patients with known heart, liver or kidney disease/malfunction. Some chemical peels used are:
- Glycolic acid (an alpha hydroxy acid) is made from milk or fruit acids is contraindicated in certain conditions like contact dermatitis. It is best at 70% concentration peel done every two weeks for 5 treatment sessions.
- Jessner's Solution is a combination of salicylic acid, resorcinol and lactic acid. It is weaker than resorcinol and is contraindicated in inflammatory conditions, delayed healing and recent reinoid therapy.
- Pyruvic Acid, a powerful alpha keto peel has anti-microbial and sebum control properties on top of its collagen forming properties. For moderate scars, 40-70% concentration is recommended.
- Salicylic Acid at 30% concentration is effective. This is recommended for dark skin as post inflammatory hyperpigmentation is considered very rare.
- TCA or trichloroacetic acid can be used for mid -moderate peels but should not be used at over 35% preparation because it can cause scarring. it is not recommended for dark skin because of hyperpigmentation issues post treatment. There is a special technique called TCA Cross which can use higher concentrations on focused applications (which avoids normal skin).
TCA CROSS means Chemical reconstruction of skin scars with 100% TCA or trichloroacetic acid solution. Strictly speaking, it is not a "peel". It is very effective when focally applied to atrophic scars. It may be the best and easiest treatment for deep ice pick scars. The doctor typically uses a toothpick or injects on the surface of the scar using micro droplets of the 100% TC solution. It is well tolerated and patients don't have to be numbed. Improvement is fast and visible at 5 days. Those with Asian or colored skin may experience PIH or post inflammatory hyperpigmentation but this is not a contraindication to the treatment. Success rate is very high and the cosmetic results are excellent. It is also cost-effective and can be used in combination therapy.
Laser therapy can either be ablative or non-ablative. Ablative laser penetrates and vaporizes the skin and is good for both superficial and moderate rolling or boxcar-type scars. It is often referred to as carbon or YAG laser and is not recommended for keloid formers. Fraxel laser is effective for scars, melasma and age spots.
BBL, the non-ablative laser (like what we have at Juvly), is less traumatic and does not vaporize skin. It stimulates the collagen underneath and raises it so that the scars are less noticeable.
It makes sense to fill craters and Bellafill does this with satisfying results that last over a year. Bellafill has extremely fine microspheres made of polymethylmethacrylate (PMMA) suspended in collagen gel. It is the only FDA-approved dermal filler for atrophic acne scars and is longer lasting than hyaluronic acid fillers like Juvederm or Restylane. It works by filling immediately and restoring collagen by acting as a framework to build on (delayed, sustained effect). It lifts and smoothes out indentations as the gel is injected beneath the acne scar by a fine needle. It is extremely well tolerated and have few complications.
Results are immediately noticeable and there is no downtime. Just make sure you aren't allergic to Lidocaine or Bovine collagen
Microneedling, a process which entails intentional "wounding" of the skin or "tunneling" until a fine spray of blood is created works on the principle that collagen can be inducted. it has shown amazing results for mild to moderate scars but for deep scars, specially ice-pick scars, the combination of ablative laser and fillers is the tandem to beat.
At Juvly, we perform ONLY non-surgical treatments. These are other acne scar treatment therapies that are recommended for deep atrophic and hypertrophic scars.
1. Silicone Gel
2. Intralesional Steroid Therapy
Acne.org has listed non-surgical and surgical ways to treat all types of acne scars. Find a doctor who you can trust with your aesthetic goals. Severe scarring may not fade into oblivion (even with agressive techniques, surgery and multiple treatments) but will be diminished enough to allow you to face the world with confidence. The table below was modified from Acne.org data.
|Proposed Management||Type of Scar/Hyperpigmentation Targeted|
|Laser CO2||Boxcar, Ice pick, Rolling|
|Laser Fractional Laser (eg. Fraxel)||same|
|Augmentation fillers||Boxcar, Rolling|
|Punch or Elliptical excision/elevation||Boxcar, Ice pick|
|Chemical Peels (light/mild)||Red marks, Hyperpigmentation, improves skin|
|Chemical Peels (medium), TCA CROSS||Box car, Ice pick, Rolling|
|Chemical Peels (deep), TCA CROSS||Box car, Ice pick, Rolling|
|Microneedling||Redness, Hyperpigmentation, Box car, Rolling|
|Steroid Injection||Hypertrophic scar|
|Cytotoxic Injection||Hypertrophic scar|
|Silicone Gel||Hypertrophic scar|
|Improves skin quality but does not diminish scars:|
|Topicals* (topical Hyaluronic Acid Serum when used with CO2 laser was very effective)|
So many ways to skin a cat when it comes to acne scar treatment, but it all begins with prevention and managing active acne. Scar revision should be done three months after acne has resolved. Use skincare formulated for your condition and wipe on gently (not rub!). Some patients who are impatient with results go as far as injecting themselves with saline solution (for depressed scars). Rather than do this, go through available options with your doctor. Your skin IS a precious commodity so trust science and your skilled and experienced providers.
2. American Journal of Dermatology and Venereology
p-ISSN: 2332-8479 e-ISSN: 2332-8487
2017; 6(2): 17-24
6. C. I. Jacob, J. S. Dover, and M. S. Kaminer, “Acne scarring: a classification system and review of treatment options,” Journal of the American Academy of Dermatology, vol. 45, no. 1, pp. 109–117, 2001.
7. Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/
8. Antonella Tosti, Maria Pia De Padova, Kenneth R Beer
Acne Scars: Classification and Treatment, ISBN 9781841846873
9. Citation: Fabbrocini G, Vita VD, Cozzolino A, Marasca C, Mazzella C, et al. (2012) The Management of Atrophic Acne Scars: Overview and New
Tools. J Clin Exp Dermatol Res S5:001. doi:10.4172/2155-9554.S5-001
For Figure 1: Types of Atropic scars grpahic