Acne Scars: The Ultimate Guide To Treatment Of Depressed Acne Scars

Acne scars are the battle wounds of past breakouts

Acne scars are a reminder that the battle against acne is only half won even after sending our active acne into remission. These “battle scars” not only puncture holes into our self-esteem but are a major cause of stress as well. It is naïve to believe that acne is solely a teenage occurrence. In fact, there are many individuals who still continue to be plagued by it – in varying degrees of severity – well into their adulthood.

How do acne scars develop? What are the different types of acne scar?

To fully understand the treatment of acne scars, it is essential to first know how acne scars develop. Rather counter-intuitively, our body’s natural wound healing process is in why acne scars form. Acne is an inflammatory process that affects different layers of our skin. This triggers a cascade of events which attempt to repair the damaged skin and in the process, depressed scars may form. Most often, there are scar fibres holding the damaged skin down and collagen has been lost from the site of acne scars, causing depressed acne scars to form.

Generally, we can classify acne scars into atrophic[1] or hypertrophic[2] in nature; atrophic scars being more common than hypertrophic ones. Atrophic acne scars are also known as depressed acne scars. There are 3 further sub-categories of atrophic/ depressed acne scars, namely, icepick, boxcar and rolling.

There are other types acne scars which may present with other features such as redness and they are treated in a different manner.

There are different treatment options for acne scars in Singapore, however, the best treatment for acne scars is a personalised treatment for every patient. Every case of acne and acne scars is different in everyone, so a treatment plan that is tailored to target your acne issues will work best.

This  article is a review on how acne scars can be best treated, common questions and side effects of acne scars treatment.

1. Secret RF and Infini RF for depressed acne scars

Secret RF and Infini RF, both fractional radiofrequency microneedling treatments are by far, the best treatments for very deep depressed acne scars, including the most difficult of them all to treat- ice pick scars. The unique fractional radiofrequency microneedling technology allows even atrophic scars as deep as 3.5mm to be targeted. By going down to the root of the scars, Secret RF and Infini RF effectively ablate the scar fibres and build collagen in the depressed acne scars, allowing these atrophic scars to rise so that the atrophic acne scars become more shallow.

2. Fractional CO2 laser for depressed acne scars

Fractional CO2 laser is one of the staples for treating depressed acne scars. Medium depth acne scars ~1.5mm can be effectively treated with fractional CO2 laser. Very fine and precise beams of laser energy are delivered into the dermis to stimulate repair of the scars and the skin’s natural collagen and elastin formation. This natural collagen and elastin fibres gradually allow the depressed acne scars to become less shallow. Fractional CO2 laser is also suitable for treating other types of scars such as chicken pox scars and traumatic scars.

3. Subcision of depressed acne scars

Some of you might have read that subcision works best for ice pick scars. That is partially true- subcision works for most types of depressed acne scars, including rolling and box car acne scars. Subcision works on the principal that atrophic acne scars are attached to underlying structures of the skin by fibrous bands of tissue. Hence, by severing the fibrous tissue holding back the atrophic acne scar, the scar is then “released” and will thus have a less depressed appearance. In addition, this process also allows some stimulation of collagen formation to take place, thus further smoothening out the appearance of the scar.

During subsicion of acne scars, a specialised needle is used to break fibrous tissue present in the dermis of the atrophic acne scar after the skin has been numbed. It is particularly useful for atrophic acne scars, stretchable scars from injury or surgery and chickenpox scars.

It is to be noted however that there are certain contraindications to undergoing subcision of atrophic acne scars. They include:

  • Personal history of being prone to hypertrophic and keloid scarring
  • An active skin infection
  • If the patient is currently taking blood thinning medications or has a known bleeding disorder

4. Dermal fillers for acne scars

Dermal filler are a soft gel made up of hyaluronic acid, a naturally occuring substance in our skin. Hyaluronic acid has the ability to attract water molecules 100x its weight, so it can plump up the skin and tissues. You might be familiar with Skinboosters, a type of hyaluronic acid dermal filler that is injected superficially into the skin to hydrate skin.

By injecting hyaluronic acid dermal fillers into the depressed acne scars, these atrophic scars are immediate raised for a shallower appearance. The hyaluronic acid also continues to draw water molecules to the atrophic scars to further push up the depressed acne scars.

5. Chemical peels i.e. TCA cross peel of acne scars.

One of the oldest but very effective treatments for depressed acne scars are chemical peels. TCA cross peels involve careful and precise placement of high concentrations of trichloroacetic acid (TCA) into the depressed acne scars. The TCA causes a localised inflammatory reaction that stimulates the dermis of the skin to form collagen to push up the atrophic acne scars.

One of the side effects of TCA cross peels for acne scars is burns. This is why chemical peels, especially TCA chemical peels should only be performed by experienced doctors for the safest and best outomes. My practice is to combine TCA cross peels with lasers so that the recovery time is kept to as low as possible.

6. Pico MLA

When you hear of Pico lasers, the first though that comes to your mind is that Pico is used to treat pigmentation. But do you know that the Pico Laser can actually be used to treat acne scars too? With a unique hand piece called the Micro Lens Array (MLA), this MLA hand piece is able to generates Laser Induced Optical Breakdown(LIOB), which is essentially a large amount of energy transferred to the deep layers of the skin while preserving the top most layers of the skin, leading to collagen regeneration and scar remodelling. This gives the Pico MLA the famous nick name called the Pico Laser Bubble Lift. A treatment that specifically treats acne scars and large pores.

This is in contrast to the traditional way we use ablative lasers such as the fractional co2 lasers to treat acne scars. With ablative lasers, columns of laser beam penetrate from the outside through the epidermis and into the deeper layers of the skin resulting in significant redness, brow scabs and downtime. Careful attention to laser settings and post laser care is also required to prevent any side effects and post inflammatory hyperpigmentation (PIH).

Pico MLA is able to penetrate into the deeper layers of the skin without damaging the superficial layer. It allows for deep penetration of the laser energy to allow for collagen stimulation hence helping with wrinkles, pores and deep acne scars.

Conclusion:

These are the 6 common treatments for depressed acne scars in Singapore. Please note that this review of acne scars treatment does not substitute a doctor’s consultation. To understand the best options for your acne scars, please seek a doctor’s consultation.

Lastly, Secret RF is a revolutionary, novel fractional radiofrequency microneedling technology that’s the first of its kind in Singapore. I’ll be sharing more about Secret RF in future blog posts, so please stay tuned.

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References:

1. Fabbrocini, G., Annunziata, M. C., D’Arco, V., Vita, V. D., Lodi, G., Mauriello, M. C., . . . Monfrecola, G. (2010). Acne Scars: Pathogenesis, Classification and Treatment. Retrieved May 14, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958495/

2. Connolly, D., Vu, H. L., Mariwalla, K., & Saedi, N. (2017, September). Acne Scarring — Pathogenesis, Evaluation and Treatment Options. Retrieved May 14, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749614/

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4720458/

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