Management of a Acne Scarring
Abstract
Acne scarring is a fibrous
process involving new collagen production to heal a
wound. It affects those with acne vulgaris and is predominant
in nodulocystic acne [1]. Options for treatment
depends on acne scarring severity, scar type
(Table 1), scar site and patient skin type, choice of
treatment modality and side effects risk profile. This
paper attempts to share with you the management
of acne scarring [2].
Different types of scars Symptoms
Flat scars These can be red, brown or pale flat
marks
Mild hypertrophic and atrophic scars Sunken or
raised scars, not visible at distances of 50cm or more
Moderate hypertrophic and atrophic scars Visible
at distances of≥ 50 cm, camouflaged and can be even
out by stretching the skin
Severe hypertrophic and atrophic scars Visible
at distances ≥ 50 cm, difficult to be camouflaged and
cannot be even out by stretching of the skin
Unfortunately, hypertrophic or keloid scars tend to
reappear even after a good result is obtained post
treatment. Traditionally, scar revision surgery is employed.
Ablative lasers, carbon dioxide and erbium
YAG laser are successful for surgery. To improve the
color of scars, Pulse Dye Laser (PDL) has been effectively
utilized. The PDL can reduce erythema and textures
of the scar. Multiple treatments are needed.
A microneedle radiofrequency laser, an example
of which is the INTRAcel from Korea, has produced
significant results. It uses an insulated microneedle
that delivers radiofrequency energy to the dermis,
reducing damage to the epidermis, hence speeding
up recovery. In my practice, I use a schedule of 4 sessions
of INTRAcel, and can achieve results of 60% upwards
for acne scars. More recently, the plasma laser
have been used, achieving good results with minimal
downtime and epidermal damage.
Ultimately the challenge is true acne scars never
completely fade, although they visibly improve as
time passes. The good thing is, they can be concealed.
Patient skin type is also an important factor.
Skin type can be classified from Fitzpatrick 1 to 6.
Darker skin types have a higher risk of post inflammatory
hyperpigmentation. Hence they benefit
more from fractional laser compared to traditional
full ablative lasers. Scars can occur anywhere on the
body, although the upper chest and shoulders are especially
prone to them. This is due to poorer regeneration
capability, from the lower density of adnexa
structures (sebaceous glands, hair follicles).
Technology and Treatment Factors
The major complication of acne is scarring, which
results in severe comorbidity for patients. On the
bright side, there exists several options to treat acne
scarring. Studies support combination treatment to
achieve the best results. The safety and efficacy has
good evidence, but there is a dearth of split-face trials
[3].
Scar types and treatment
• Grade 1 scars: Topical treatment with silicone
based gels combined with careful use of pigment,
vascular and fractional lasers.
• Grade 2 mild scars: Fractional, vascular and pigment
lasers as well as microneedling. • Grade 3 scars: Full ablative and fractional lasers,
and may require scar revision occasionally.
• Grade 4 scars: Require a multimodality approach
[4].
Ablative laser: Ablative laser resurfacing utilizes
electromagnetic waves to erode the entire epidermis
and upper layer of dermis. Fractional laser treatment
addresses both the epidermis and dermis. It
delivers hundreds of laser beamlets. The principle
is controlled dermal damage in MTZ (Micro Thermal
Treatment Zones) in order to stimulate fibroblast to
aid collagen remodeling and neocollagenesis. MTZ
are selected areas with dermal injury, while sparing
adjacent areas. They areas with injury would in turn
kick start the process of neocollagenesis, while the
adjacent areas maintain cell renewal and healing. In
this way, the electromagnetic energy is effective yet
safe, meanwhile keeping surrounding tissue healthy,
aiding wound healing. This leads to faster recovery
and less downtime. Today, the main laser resurfacing
treatments can be divided into the non-ablative
and the fractional. Techniques using other modalities
may include microneedling, high intensity focused
ultrasound systems and platelet rich plasma amongst
others [5].
Non ablative laser
Non ablative lasers deliver electromagnetic energy
into the dermis, inducing selective injury, leaving the
epidermis untouched. The safety profile and speedy
recovery have more than compensated for its slower
results. And in today’s day and age, the public want
treatments that have minimal downtime. There are 3
main types of non-ablative modalities, mid-infrared
ones, the Pulse dye lasers (PDL) and broadband light
systems. These lasers work well for dyschromia but
the textural improvement in scars is minimal [6].
CO2 ablative laser was the primary modality for the
treatment of acne scars. However, it has extensive
downtime of 2 or more weeks. Erbium YAG laser has
slower clinical efficacy, shorter downtime and minimal
recovery time. Now, the focus is on multi- modality
treatments to achieve good results, safe and
effective with low downtime. Hence the popularity
of fractional lasers [7-9].
Side Effects: Side effects include redness and swelling,
skin dyschromia, scarring, skin infections, eczema
etc. After ablative fractional lasers, these following
are common side effects, especially over the
neck.
To bring it to another level, RF microneedling is a
new technique invented in Korea. It works to reduce
scars, both atrophic and hypertrophic scars. The science
is dermal matrix remodeling. The downtime is
minimal; must less than fractional lasers, the side effects
of post inflammatory increased pigmentation
on darker skin types is much reduced, and the results
are comparable [16].
Dermal fillers: A soft filler like restylane vital can be
used to fill up the depression in atrophic scars, and
subcision can be employed to breakdown the fibers
that are anchoring the skin down. In my practice, I
commonly combine this with RF Microneedling or
fractional laser, over 4 sessions, and the results are
significant. Studies have noted the use of PRP can
speed up recovery [17].
Plasma laser: This relies on the 4th state of matter to
ionize particles. It removes oxygen from cells, hence
reducing the risk of charring the skin. The heat reaches
a good temperature to stimulate neocollagenesis
to improve scar texture and tone. The safety profile
is high, with low risk of hypopigmentation and hyperpigmentation.
