How acne scars are treated

Acne scar treatment forms an important part of physical treatment which is essential to obtain maximum therapeutic results.

Types of scars

Scar therapy depends on the type of scar, which determined by their shape, number, depth, localization and duration. It also depends on the patient’s skin and localization of the lesions.

1) No loss of tissue: Macules or “pseudoscars” are flat reddish spots in the final stage of inflamed lesions. The site is pigmented and mostly occurs in darker skinned people.

2) Increased tissue: Hypertrophic scars or keloids result from increased tissue formation and excessive collagen. These are also seen mostly in darker skinned people.The more common are four types of scars caused by loss of tissue.

3) Loss of tissue: These are of four types depending on their shape.

a) Ice pick scars occur on the cheek, look like someone has used a little ice pick. The lesions have jagged edges.
b) Box scars are large, U shaped depressed fibrotic scars with sharp edges and steep sides.
c) Rolling scars are deep and soft and have gently rolling edges which merge with the skin.
d) Atrophic scars are small, white and soft and barely raised above the surrounding skin.

Treatment

Risks and benefits of all forms of treatment should always be discussed with your physician. It is important to have a realistic expectation from the treatment. It is also important to understand that complete erasure of the scar may not be possible and for best results multiple treatments may be required.

Physical treatment are generally not done on patients who have recently undergone oral therapy or have a history of keloids, or persistent facial acne.

Types of treatments

A) Collagen injections: Collagen is injected under the skin to fill deep soft scars and results last for 3-6 months. Further injections may be needed for recurrence. It is not suitable for ice pick scars and keloids.
B) Autologous fat transfer: Here depressed scars are raised by taking fat obtained from another part of the body and injecting it under the skin surface. Since the fat is absorbed in 6 to 18 months the procedure must be repeated.
C) Dermabrasion: Here under local anesthetic, a brush or a fraise removes the surface skin and changes the contours of the scars. Superficial scars can be completely removed and the depth of deep scars can be reduced. This treatment does not work on ice pick scars, U shaped scars and on scars that are wider under the skin than on the surface. It is also not ideal for dark skinned patients since it causes discoloration needing further treatment. Microdermabrasion uses aluminium oxide crystals passing through a vacuum to remove surface cells, avoiding further wounds. Microdermabrasion can be used on small and faint scars but it is not powerful enough for other acne scars.
D) Chemical peels: The three types of chemical peels used are superficial, intermediate and deep peels.
i) Superficial peeling has the highest risk-benefit ratio, i.e. have greater benefit for lower risks or side effects. It can remove macular scars and the accompanying pigmentation, the skin gets a healthier complexion and the size of the skin pores is reduced. Ice pick and U shaped scars can also be treated by this method. The skin has to be prepared for 15 to 30 days before treatment with keratolytic products and depigmenting creams. Side effects include erythema folliculitis, flare of acne lesions and hypopigmentation or hyperpigmentation.
ii) Intermediate and deep peeling have a lower risk-benefit ratio and the effect on atrophic scars is mild and for a shorter duration. They have no effect on keloids. The risks of scarring and pigmentation are increased.
E) Laser resurfacing: Laser therapy is non-invasive, does not require anesthesia, is less painful and results have been encouraging. Erythema is the commonest side effect (54%) and can last for longer than three months. Hyperpigmentation is the second most common side effect (29%) but is seen to fade within 3 months. Lesion flare-ups occurred in 29% cases. Different types of lasers can be used to achieve different results. Longer wave-length lasers achieve quicker results. The pulse-dye and intense pulse light laser can raise depressed scars and improve hypertrophic facial scars. High energy pulsed CO2 lasers have good results with atrophic and shallow U shaped scars, improving skin appearance by giving it a more homogenous look.
F) Surgery: Punch excision can treat ice picks and deep scars simultaneously if they are at least 4 to 5mm, and involves removal of the involved tissue with a punch biopsy. The wound is then allowed to heal on its own and results in a tiny flat scar which is usually smaller than the original lesions.

Punch elevation combines punch excision followed by skin grafting (where skin from another part of the body such as the thigh or from behind the ear is taken and placed on the wound produced by the punch excision). This method has shown to produce healing without causing skin color or texture mismatch. A necessary condition in this treatment is that the scars should have sharp edges and normal bases. Box-car scars therefore cannot be treated with this method. Skin grafting is especially needed to close the defect of unroofed sinus tracts.

Combination treatments

Each type of scar has an optimal treatment method. Sometimes combination of various treatments may be used to get the best result. For example, punch excision and elevation needs to be combined with laser resurfacing to improve skin appearance.