Dr. Sue Ann Wee is Board Certified Dermatologist with expertise in laser surgery, cosmetic, and medical dermatology. I got the opportunity to ask her a few questions about acne scarring and the treatment options that are available for those suffering from acne scarring.
Why does acne scarring occur?
When acne occurs, it is accompanied by an inflammatory response which injures the skin. This injured area of skin then undergoes wound repair in which the body produces scar tissue (collagen) to heal the wound. Although, the body replaces injured tissue with the same type of tissue (collagen) that is present in normal tissue, scar tissue lays down collagen in a different and inferior manner compared to normal tissue collagen. This different arrangement of collagen in the body’s healing process is the key feature of scar formation.
What are the different types of acne scars?
There are 5 main types of acne scars: rolling, box-car, ice-pick, hypertrophic, and keloid. Rolling acne scars are typically shallow, soft wave-like recessions in the skin whereas box-car scars tend to be more angular recessed scars with vertical edges. Ice-pick scars appear as deep, narrow pits in the skin. Hypertrophic scars are usually raised and firm but can less commonly be soft and protuberant. Keloid scars are larger than hypertrophic scars because they extend beyond the original area of injury to the skin. Most acne scars are initially pink or reddish in appearance which may last just a few weeks to many years or more.
picture source: acne.org
Can acne scars be treated if the patient still has acne?
Yes, various treatment modalities can be used or combined to treat acne scars even during an active acne flare. For example, hypertrophic scars can easily be injected with steroid which can flatten scars. I treat patients with photodynamic therapy utilizing a variety of lights and lasers to simultaneously treat both pink or reddish acne scars and active acne. Other benefits of photodynamic therapy include less oily, healthier skin, and improved pore appearance and skin texture. It can be a great alternative to oral antibiotics and isotretinoin (Accutane) in patients who wish to avoid taking pills. Before performing laser resurfacing on a patients’ acne scars, I will use a variety of topical and/or systemic therapies to control the acne first.
When should you seek professional treatment for acne scarring?
Patient should seek professional treatment when they have acne flares that are leading to acne scars. Aggressive treatment of active acne is the best way to prevent further scarring. Also, patients who have acne scarring may want to seek treatment when it begins to affect them in their daily life. However, if the patient has recently been on isotretinoin (Accutane), then they must wait at least 6 months before laser resurfacing and/or other acne scar treatments.
What kind of treatments are available for those with acne scarring?
There are many treatment options for acne scarring. Fractional laser resurfacing is an excellent treatment option for acne scarring. Fractional lasers deeply treat tiny columns of skin, leaving surrounding skin intact. There are two main types of fractional resurfacing lasers: non-ablative (no open wound) and ablative (open wound) lasers. Non-ablative fractional resurfacing lasers are an excellent choice for most types of acne scarring because they require very little down-time for patients (approx 2 days), can be safely used in lighter and darker skin types, and produce significant improvement in acne scars over a series of treatments. Ablative fractional laser resurfacing uses the more aggressive CO2 wavelength that results in open wounds with longer down-time(weeks); however, fewer treatments are generally required. Ablative resurfacing lasers should be used with great caution in darker skin types as there are more risks for pigmentation and scarring. Although there are many similar lasers, Fraxel Restore is the original and most studied non-ablative fractional laser. Its ablative counterpart is Fraxel Repair.
There are also lasers that can reduce the pink or reddish discoloration of acne scars (pulsed dye lasers). Raised hypertrophic and keloidal acne scars can be injected with steroid to flatten them.
If a patient also has ice-pick scars or very deep recessed scars, then additional treatments such topical acids can be applied directly into the scars to build collagen and improve them. Alternatively, severely recessed acne scars can also be filled or ‘plumped up’ by injection of fillers which have variable duration of benefit depending on the choice of filler. Severely recessed box-car or pitted acne scars can also be surgically cut out using punch-excision techniques.
Superficial chemical peels offer little improvement for acne scars; however, medium strength chemical peels and mechanical dermabrasion can improve acne scars but carry more risks and side effects compared to non-ablative fractional lasers. Patients often ask me if microdermabrasion is helpful for acne scars and the answer is no; microdermabrasion does not penetrate into the deeper layers of the skin where the acne scarring problem lies.
Of course, no acne scarring treatment is complete without a plan tailored to each patient to discourage future acne.
About Dr. Sue Ann Wee
Dr. Sue Ann Wee is Board Certified Dermatologist with expertise in laser surgery, cosmetic, and medical dermatology. Dr. Wee obtained her medical degree from Stanford University School of Medicine and completed her dermatology residency at New York University School of Medicine. She pursued further training by completing a Laser and Cosmetic Surgery fellowship in Boston, Massachusetts under the direction of faculty from Harvard and Yale University School of Medicine. She practices dermatology at Manhattan Center for Dermatology and 5th Avenue Dermatology Surgery and Laser Center in New York City.