Acne scarring and post-inflammatory hyperpigmentation (PIH) is a common occurrence that patients experience after a breakout.
Roughly 1% of the population develops acne scars, with Asians being more prone to PIH than other skin types. As scarring develops in the deeper layers of the skin than acne itself, this is why acne scar removal can be challenging.
To quickly recap, acne scars are a result of skin damage that occurs during the wound healing process after a breakout. They can be categorized into two main groups: atrophic and hypertrophic scars, with atrophic scars being the most prevalent type that makes up 90% of all acne scarring.
Atrophic scars are a result of a lack of collagen remodelling that results in depressions and uneven texture of the skin and can be further divided into boxcar, rolling and icepick scars.
Boxcar scars: Broad depressions with sharply defined edges.
Rolling scars: Angular in shape with broad depressions and a sloping edge.
Icepick scars: Deep, narrow and pitted scars that are the hardest to treat.
Acne scars have been shown to negatively impact the quality of life and mental well-being of patients. As we continue to lose collagen due to the natural ageing process, depressed acne scars will only get worse, making it vital for you to start treatment as soon as possible.
But what is the best treatment to get rid of acne scars?
Fractional CO2 laser: the gold standard of acne scar treatment
Laser resurfacing is a valuable treatment for atrophic scars as it helps to remodel the skin’s surface by removing the uppermost layer of the skin while promoting collagen production.
Although there are other solutions such as TCA cross, chemical peels and dermabrasion—fractional CO2 laser has allowed doctors to achieve better results while eliminating the cons of ablative lasers which although was effective, resulted in longer recovery times, more discomfort and greater thermal damage to the skin.
Since fractional technology only treats a fraction of the skin’s surface at a time, this ensures that the surrounding skin is left unharmed during the treatment.
The fractional CO2 laser also boasts one of the longest wavelengths of laser devices and is great for treating all types of depressed, atrophic acne scars. It can even treat enlarged pores, uneven skin texture and promote overall skin rejuvenation!
By emitting a zone of microbeams in the deeper layers of the skin, this kickstarts microscopic thermal injury where scarring is found to induce collagen production while sparing the surrounding healthy tissues. Your skin then starts to repair itself at a faster rate by rebuilding any lost collagen to even out any scarring.
The treatment can be done in just 30-60 minutes (including the application of local anaesthesia) and completed over 4-6 sessions for best results. The majority of patients will begin to see initial results after one week, with ongoing improvements for about 6 months.
The treatment is largely tolerable for the majority of patients and some redness or swelling after the treatment is completely normal and will usually subside within the first week. Since fractional CO2 laser is a highly customizable treatment, our doctors can personalize treatment parameters according to your skin type and condition.
A 2013 study with 25 Asian patients with atrophic acne scars showed that a single treatment with fractional CO2 laser is effective with minimal and acceptable side effects, with even bigger improvements at the 3-month mark.
It is very possible to achieve an improvement of up to 75% at the end of an entire treatment course!
INFINI RF: a powerful treatment for deep acne scars
Radiofrequency (RF) micro-needling is a treatment that promises better results than the fractional CO2 laser, especially for patients with deep acne scars. It combines two treatment techniques into one to offer deeper energy delivery and insulated micro-needles to break down old scar tissue while providing a higher safety profile as it protects the epidermis from thermal heat energy.
INFINI RF is an FDA-approved RF micro-needling treatment that penetrates up to 3.5mm into the skin as compared to up to 1.5mm for fractional CO2 lasers. By delivering multiple passes at different depths in the skin, it provides a 3-Dimensional delivery of energy to maximize skin volumizing, reduce acne scars and tighten skin!
While fractional CO2 laser stimulates collagen production, INFINI RF triggers both collagen and elastin production to further boost overall skin rejuvenation! Because it can be infinitely controlled (hence its name), our doctors can customize the energy, depth and duration of the treatment according to your needs and goals.
Since the treatment is “colour-blind”, this means that it does not run the risk of causing hyperpigmentation unlike traditional light energy lasers and is safe for all skin types!
INFINI RF treatment provides excellent results for deep, boxcar and rolling scars. The entire treatment takes roughly 20 minutes to complete and patients will need anywhere from 1-8 treatment sessions at intervals of 4-6 weeks depending on the severity of scarring. The downtime required is 3-5 days where you can expect to see results after a month since time is needed for cell turnover to occur.
Subcision: a manual technique for tethered, depressed scars.
There are certain scars that are hard to treat with laser techniques as they are unable to reach the deep muscle layers where tethered scars are found. Studies have shown that subcision is especially effectively for releasing tethered, rolling scars.
Subcision is a surgical technique that involves a doctor manually breaking down the tight collagen bands that are attached to the subcutaneous tissues below the skin.
During the treatment, our doctor will insert a hypodermic needle to help release the scar tissues that are anchoring down the skin. The needle is moved back and forth in a “fanning” motion under the skin tissues to stimulate collagen production and induce wound healing to improve the appearance of your scar.
Local anaesthetic is applied before the procedure to ensure maximum comfort throughout the procedure, and patients can expect some slight swelling and tenderness that should subside within a week. 2-4 sessions are required for moderate scarring at 4-week intervals where acne scars can be expected to permanently improve by 1-2 grades at about 6 months after the surgery.
At our clinic, we believe in combining subcision with dermal fillers to achieve an immediate lifting effect and to prevent the short-term reattachment of your scars. The results of this treatment is highly dependent on the skills of the doctor—employing the proper techniques and best practices ensures you get the most out of each session.
Dermal Fillers: ideal for filling depressions and promoting skin regeneration
Dermal fillers are great for boosting the effects of your acne scar treatment by triggering collagen production and smoothening out your skin texture.
At our clinic, the Ellansé filler is a popular choice that provides natural-looking and enduring results that can last up to 4 years!
Other dermal fillers include Restylane, Juvederm and Rejuran Healer. The majority of injectables are primarily made up of hyaluronic acid (HA) that can help stimulate collagen production and reverse the signs of aging. In the case of acne scars, it helps to elevate the scar tissues and lift it temporarily. As HA is a substance that is naturally found in the body, this makes dermal fillers safe with minimal side effects when done by a competent doctor.
What makes Rejuran different from traditional dermal fillers is that it is made out of the key ingredient polydeoxyribonucleotides (PDRN) which strengthens the skin’s barrier and encourages wound healing and regeneration.
Rejuran S is specifically designed to treat acne scars as it is more viscous than Rejuran Healer to give an immediate volumizing effect post-subcision. It is highly recommended to complete 3-4 treatment sessions at 2-4 week intervals to achieve the best results.
As most dermal fillers only provide temporary results, patients will have to come back to get maintenance treatments at regular intervals, typically every 1-2 years. Regardless, dermal fillers are ideal for shallower atrophic scars that can be effectively combined with INFINI RF, subcision or fractional CO2 laser!
Pico MLA: treat acne scars and enlarged pores with lesser downtime
The Pico laser is one of the latest technological advancements that can be used to treat enlarged pores and acne scarring at a much faster rate than traditional lasers.
The HEXA MLA (Microlens Array Technology) is an extension of the powerful pico laser that delivers light energy at rapid speeds at ultra-short pulse durations to distribute energy at a faster rate (one trillionth of a second), producing up to 15 times more pulses within each individual shot for quicker results!
The addition of the handpiece gives our doctors a higher peak power to work with due to an effect called Laser Induced Optical Breakdown (LIOB) that causes tissues to be rapidly energised to elevate and push depressed acne scars up. In short, this means lesser treatment sessions required and faster results!
The ultra-fast speed of the laser produces a greater photoacoustic effect versus photothermal effect which results in less discomfort and minimizes the chance of PIH. There may be some scabs that form 1-2 days after your treatment, and it is important to protect your skin from excessive heat and sun exposure during the healing period.
As the handpieces comes in various spot sizes (3-10mm), this allows our doctors to accurately treat your condition and produce consistent results. Unlike most traditional ablative lasers, PICO MLA does not breach the superficial skin, thus minimizing side effects and promoting better healing times. Best of all, the procedure takes just 10 minutes and one treatment session is enough to see results!
TCA Cross: an effective solution for deep, ice-pick scars
TCA Cross (chemical reconstruction of skin scars) is one of the best ways to treat deep, ice-pick scars where laser treatments aren’t able to produce satisfactory results.
Using trichloroacetic acid (TCA) at high concentrations (70-100%), small amounts are applied onto the surface of the atrophic scar while avoiding areas of healthy skin to cause a local inflammatory reaction. A white frosting is seen on each scar which disappears in 20-30 minutes. This process induces collagen production to increase dermal volume and restructuring of the dermal elements within the skin to take place, causing the scar tissue to rise and improve over time.
2-6 treatments are recommended at 4-6 week intervals to allow skin healing and collagen remodelling to take place. Although there can be some temporary pigmentation and minor scabbing, this is completely normal and part of the natural healing process. An ointment will also be given for patients to apply at regular intervals to aid healing. Studies have also shown that TCA cross demonstrates good improvement after 3-6 treatments in more than 90% of cases.
The treatment is suitable for all skin types and is effective on its own for treating mild-to-moderate scar types. In fact, hard-to-treat ice-pick scars tend to respond very well to this treatment. Overall, this is a straightforward and cost-effective procedure with exceptional outcomes and few complications.
Which is the best acne scar treatment for me?
The best acne scar treatment must always utilize a combination approach. Multiple studies have concluded that using a multimodal and varied approach creates better responses and higher patient satisfaction rates. Research also shows that combination therapy is key to avoiding side effects, especially when using just one treatment modality over time.
Although fractional CO2 laser and INFINI RF are both safe and effective treatments for treating the majority of acne scar cases, we consider INFINI RF to be the next step beyond fractional CO2 laser. In fact, we like to combine the two: by treating the upper layers of the skin first before tackling the scars down below, utilizing both treatments produces synergistic effects and boosts healing time for our patients!
A 2019 study showed that combining the use of Fractional CO2 laser and RF micro-needling treatments showed a significant improvement with shorter downtime and 90% of participants reporting excellent results!
The majority of patients will have multiple acne scar types which warrant different treatment modalities. There is never a one-size-fits-all acne scar removal treatment, which is why seeking the help of an experienced doctor who can accurately assess your skin type and condition is just as important as the treatment itself.
Start your personalized acne scar treatment today
At The Clifford Clinic, we currently offer a wide range of acne scar treatment solutions such as fractional CO2 laser, Pico MLA, Fraxel Dual and Vbeam laser that can be effectively combined to help you achieve the best results in fewer sessions. Our doctors are also highly-trained in employing manual techniques such as subcision, TCA cross and dermal fillers for synergistic results!
Secret RF is another RF micro-needling treatment that we offer that tackles both acne and acne scarring with long-lasting results. Using gold-coated micro-needles, it is able to reach up to 3.5mm into the deep skin layers (similar to INFINI RF) to trigger skin tightening and remodelling that is ideal for deep and depressed acne scars. It is also one of the best acne spot treatment for those facing recurrent cystic acne!
We cannot stress enough how important it is to select a doctor who offers a myriad of treatment modalities to create a personalized, comprehensive treatment plan just for you.
Begin your journey to clear, flawless skin—drop us a call to book your appointment today!