Acne scarring plagues the pores of so many who have long-since recovered from active acne. With the recent advent of laser technology and dermatological research, much progress has been made in understanding how to best care for patients while undergoing treatment and in improving treatment efficacy itself.
I recently discussed the subject with leading San Francisco dermatologist Dr. Caren Campbell, M.D., a physician who has treated many Millennial professionals in the area struggling to remove acne scars. Below, she shares the recent, notable progress that has been made in acne-scarring treatment options, how to know if scars will fade on their own, when to seek medical intervention and the questions to ask your physician.
First, what causes acne scars?
Campbell: Acne scars result from cystic, inflamed acne lesions. When the clogged, inflamed pore ruptures, the skin’s attempt to repair the broken skin isn’t as flawless as the original skin. Depending on the depth of the ruptured pore, varying types of acne scars can be produced—atrophic, icepick, boxcar, rolling. When the body overshoots the wound healing response keloids or hypertrophic scars can form, which represent excess scar tissue formation.
Will they ever fade on their own?
When discoloration is the issue and the “scar” is flush with the skin and there is no surface irregularity, these do resolve on their own with time and sun avoidance. For acne scars not flush with the skin, they typically do not fade on their own. Collagen in the skin needs to be remodeled or stimulated to correct for these structural deformities in the skin.
Discoloration from acne is called post-inflammatory erythema if red and post-inflammatory hyper-pigmentation if darker than normal skin tone. This discoloration of the skin that is flush with the skin is caused by the inflammatory cells that attack the overgrowth of bacteria, oil and dead skin clogging the pore. Even after the acne has resolved, this pigment change remains though will fade with time. Sun avoidance and protection are important is helping this pigment change fade more quickly. If the areas of post-inflammatory erythema or hyper-pigmentation are exposed to sun they persist longer. Sunscreen that is SPF 30 or higher, broad spectrum and ideally mineral is recommended. Newer formulations like EltaMD and CCMD sunscreens (my branded sunscreen) contain nanoparticle zinc and titanium that rub in clear rather than leaving a white film.
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Additional topical treatments can be used to expedite improvement of these areas of discoloration. This includes the mainstay topical treatment for acne — retinoids. Creams like Tretinoin and Tazorac speed up skin cell turnover and stimulate collagen. There retinoid creams also have a role in remodeling scars and not only pigment. A recent split-faced study (treating one side with at-home microneedling and one side with Tazorac) showed improvement with Tazorac alone in acne scars.
Can acne scars be removed permanently?
In short, yes. Depending on the type of acne scar, different modalities may be utilized, but overall, I have found that laser treatments are the most effective option for the majority of acne scars. The two best laser devices on the market for acne scars are Fraxel 1550 and PicoWay Resolve. PicoWay Resolve is safe in all skin types as it does not heat or break the surface level of the skin. Fraxel 1550 delivers heat to the top layers of the skin which can be beneficial in stimulating collagen, but increases the risk of hyperpigmentation (dark areas of skin) in darker skin types. This risk can be mitigated with pre- and post-treatment Tretinoin and hydroquinone, but which laser is most appropriate for your skin type should be assessed prior to treatment by a board-certified dermatologist or plastic surgeon.
Why are laser treatments the most effective treatment for acne scars? They produce the most amount of neocollagensis (stimulation of new collagen and elastin, which is required to remodel acne scars). One of the only ways to stimulate collagen is to damage the skin to elicit a wound-healing response. Lasers use light energy to create these small wounds. That said, not all lasers are creating equal or powerful enough to wound the skin appropriately.
Deciding between the Fraxel 1550 and PicoWay Resolve if both are appropriate for your skin type can come down to lifestyle. PicoWay has minimal to no downtime, but does require more sessions. For patients without five days to be red and scaly (which is the result of Fraxel), PicoWay may be the more appropriate choice. For patients with a special event coming up or those wanting results as soon as possible, Fraxel 1550 would be a better option.
When Fraxel 1550 is combined with PRP (platelet rich plasma), downtime can be lessened by one-two days and more collagen can be stimulated. PRP uses the patient's own blood to stimulate collagen and remodel acne scars. My favorite PRP system is the Eclipse system. It is important to use a blood draw tube that contains the appropriate components needed to activate the platelets in the blood so they release growth factors—signals that tell your body to heal and produce more collagen .
Other modalities that can be used in combination with laser treatments include surgical removal of acne scars, subciscion (breaking up the scar tissue with a needle below the scar), microneedling, and TCA cross (a strong chemical peel solution is placed inside the depressed scar to elicit it to fill in with new tissue). Fillers can also be injected into acne scars, but these are oftentimes temporary and require repeat treatment. In your experience, what is the best way to remove them? How long does it take?
Depending on the type of scar, different modalities are most appropriate. For the vast majority of scars, I start with a series of laser treatments. Usually a series of four-six Fraxel 1550 or six-twelve PicoWay Resolve, depending on the patient’s skin type and lifestyle. If a few subset of the scars remain after a few laser treatments, TCA cross, punch excision or subciscion can be used in combination with the remaining laser treatments on a case-by-case basis.
Fraxel 1550 requires numbing with topical anesthesia for one-two hours prior to treatment. The numbing cream is removed and the Fraxel 1550 treatment takes 10-15 minutes for a full face. Afterward, your face feels warm and a cooling mask is applied for 15 minutes. One hour after treatment the skin temperature feels back to normal, but remains red in appearance. The next three-five days the skin remains red and begins to scale on day three-four and is starting to get back to normal by day five and can easily be covered with make-up.
For PicoWay Resolve, no numbing is required and the treatment for a full face takes 15 minutes. After the treatment tiny broken capillaries can result, which resolve in one-two days and can easily be covered with make-up. Some patient experience mild itching on day one-two post treatment. The redness after treatment is subtle and looks like a mild allergic reaction in some patients.
What else should people know about these treatments?
Not all lasers are created equal. You need to right temperature, the right speed of firing and the right depth and spacing of the laser beams of energy. Not all providers of treatments are created equal. An expert knows what settings will get you the most bang for your buck without increasing your risk of hyper- pigmentation, scarring, or infection. While medspas may have the same device or claim their device is of similar efficacy, this is not the case. Many years go into understanding and training on laser devices. You will get more for your money with a board-certified dermatologist or plastic surgeon who uses a tried and true laser device with appropriate settings.
Microneedling has been very popular recently for acne scars. In my opinion, the result are proving to be temporary as a lot of the improvement is from soft tissue swelling that masks the appearance of the scar for only a short time. Lasers have a longer track record for treating acne scars, particularly the Fraxel, which has proven to historically be the gold standard. PicoWay Resolve is an exciting new technology that is showing excellent results with minimal to no downtime, which in our fast paced, high demand world is really amazing for us busy working professionals.
How can you prevent future acne scarring?
Prior to treating any patient for acne scars, I ensure my patients are investing in a good skin care routine that treats and prevents future acne. Often this includes one of the two best ingredient to treat and prevent new acne from forming: retinoids and benzoyl peroxide. Retinoids combat all components of acne formation - they remove the top layer of dead skin cells which clog the pore. They also reduce oil production, which creates a good environment for the acne- causing bacteria to overgrow. Retinoids also help kill acne-causing bacteria and serve as an anti-inflammatory agent.
Similarly, Benzoyl peroxide works to fight acne by killing the acne-causing bacteria and removing dead skin cells from the pore (keratolytic). In more severe cases of acne where scarring is a significant issues, Isotretinoin is the first line treatment. Isotretinoin permanently shrinks the oil gland taking away the oil production that provides a good environment for the acne causing bacteria to overgrow. Historically, caution was taken not to treat acne scars while patients were on Isotretinoin, given the concern for impaired wound healing, but this has been debunked recently by newer studies. Back then, patients had to wait to treat acne scars for six months after completing their course of Isotretinoin. Much progress has been made.