Treatment of Acne Scars

Early Acne Scars - Prevention, Treatment, and Antioxidants
By Heather Brannon, MD

Acne is a skin condition that affects up to 80% of people in their teens and twenties, and up to 5% of older adults. While many people recover from acne without any permanent effects, some people are left with disfiguring acne scars. There are some topical skin care products and medications that can improve mild scarring, but most acne scars are treated with a combination of surgical procedures and skin resurfacing.

Early Acne Scars
After an acne lesion has healed, it can leave a red or hyperpigmented mark on the skin. This is actually not a scar, but rather a post-inflammatory change. The redness or hyperpigmentation is seen as the skin goes through its healing and remodeling process, which takes approximately 6-12 months. If no more acne lesions develop in that area, the skin can heal normally. Any color change or skin defect still present after 1 year is considered to be a permanent defect or scar.

Treating Early Acne Scars
The post-inflammatory changes caused by acne are part of the skin's natural healing process. There are certain practices and medications that can help facilitate this healing process.

• Unprotected exposure to the sun causes more skin damage and delays healing, therefore wearing a good sunscreen is important.

• Using tretinoin (Retin-A, Renova, Avita) speeds up the skin's remodeling process and helps heal post-inflammatory changes.

• Appropriate formulations of Alpha-Hydroxy Acids (AHAs) and Beta-Hydroxy Acid (BHA) that contain the correct concentrations and are at the appropriate pH also help the skin's remodeling process.

• Picking at scabs should be avoided at all costs. Scabs form to protect the healing process that is going on underneath them. Pulling a scab off before it is ready interferes with the healing and remodeling process, prolonging the time that post-inflammatory changes will be visible.

Antioxidants and Post-Inflammatory Changes
As we understand more about skin damage from free-radicals, it seems that using an antioxidant would help treat post-inflammatory changes or even permanent scars. Unfortunately no good scientific studies have shown that any oral or topical antioxidant prevents or heals skin damage. As a matter of fact, Vitamin E, when applied topically to healing wounds, has been shown to cause more harm than good. As antioxidant research continues, scientists may find a formulation that effectively reverses skin damage, but until then any claims of skin rejuvenation through the use of antioxidants are merely hype.

In July 2001 Jacob et al proposed an acne scarring classification system that also assists in determining effective scar treatment procedures. According to this system acne scars are classified as icepick, rolling, and boxcar based on the appearance of the scar. After taking into account previous accutane use, facial scars are mapped out and a staged treatment plan is developed.

Acne Scars - Icepick
Icepick scars are narrow, sharp scars that make the skin appear it has been punctured with an icepick. They are usually narrower than 2 mm and extend into the deep dermis or subcutaneous layer. Icepick scars are usually too deep to correct with skin resurfacing treatments such as dermabrasion or laser resurfacing.

Acne Scars - Boxcar
Boxcar scars are round to oval depressions that have sharp vertical edges. Unlike icepick scars they do not taper to a point at the base. Shallow boxcar scars are 0.1-0.5 mm in depth and can usually be treated with conventional skin resurfacing techniques. Deep boxcar scars are >0.5 mm in depth and require full-thickness treatment techniques.

Acne Scars - Rolling
Rolling scars occur as a result of tethering of otherwise normal-appearing skin to the subcutaneous tissue below. This process gives the skin a rolling or undulating appearance. Conventional skin resurfacing techniques do not work on rolling scars. They must be corrected by breaking up the subcutaneous fibrous bands.

Acne Scar Treatment After Accutane
An important consideration in the treatment of acne scars is the past use of accutane. There are numerous procedures that can be used to correct acne scars. Each procedure has its own risks and benefits, and several procedures are normally combined to create the smoothest appearing skin. Here is a brief discussion of the more effective acne treatment procedures.

Dermal Fillers
There are many types of dermal fillers that can be injected into acne scars to raise the surface of the skin and give a smoother look. Examples of dermal fillers are fat, bovine collagen, human collagen, hyaluronic acid derivatives, and polytheyl-methacrylate microspheres with collagen. The injection of these materials does not permanently correct acne scars, so further injections are necessary.

Punch Excision
This method of surgically correcting acne scars is used on deep scars such as icepick and deep boxcar scars. This procedure uses a punch biopsy tool which is basically a round, sharp "cookie-cutter" tool that comes in diameters ranging from 1.5 mm to 3.5 mm. The size of the tool is matched to the size of the scar to include the walls of the scar. Under local anesthesia the scar is excised with the punch tool and the skin edges are sutured together. The newly produced scar eventually fades and may not be noticeable. If it is noticeable, it is more amenable now to resurfacing techniques.

Punch Excision with Skin Graft Replacement
With this method the scar is excised with the punch tool as above. Instead of suturing the skin edges together, the defect is filled with a punch skin graft usually taken from behind the ear. With this procedure a color and texture difference may be noticeable, but a skin resurfacing technique can be used 4-6 weeks after the grafting to correct this difference.

Punch Elevation
This method of surgically correcting acne scars is used on deep boxcar scars that have sharp edges and normal appearing bases. The same punch tool as above is used to excise the base of the scar leaving the walls of the scar intact. The excised base is then elevated to the surface of the skin and attached with sutures, steri-strips, or skin glue called Dermabond. This method lessens the risk of color or texture differences as can be seen with graft replacement, and lessens the risk of producing a visible scar as can be seen when wound edges are sutured.

Subcutaneous Incision
Subcutaneous incision, also known as Subcision, is used to break up the fibrous bands that cause rolling scars. Subcision is performed under local anesthesia by inserting a specially beveled needle under the skin so that it is parallel to the skin surface. Staying in the plane between the dermis and the subcutaneous tissue, the needle is gently advanced and retracted in a piston-like motion cutting the tethering bands. This procedure causes bruising which fades after about 1 week. The risks of subcision include bleeding and the formation of subcutaneous nodules. Bleeding can be controlled with proper use of anesthetics and bandaging, and the subcutaneous nodules can be treated with injection of corticosteroids into the nodule.

Laser Resurfacing
Laser resurfacing is a popular treatment for many skin defects. The most popular laser types used for resurfacing of acne scars are the carbon dioxide (CO2) and erbium:YAG (Er:YAG) lasers. Lasers work by essentially burning the top layers of skin to a precise depth. The skin then heals replacing the burned layers with newer appearing skin. The correct post-operative care of skin that has undergone laser resurfacing is a very important factor in determining the success of the procedure.