Acne Scars are most commonly found on the face, but can occur on any part of the body. Typically, there are three different types of acne scars that are found on the skin: Atrophic Acne Scars, Dark Acne Scars, and Acne Keloids. Our board certified surgeon, Dr. Raffy Karamanoukian, is world-renowned for his advanced approach to scars. During his consultation with you, he can develop a scar treatment plan that is carefully tailored to fit your specific needs.
Atrophic acne scars represent a difficult problem for patients. Although acne scars are generally only millimeters deep, they can cause signficant shadowing and contour irregularity of the skin. These contour irregularities destroy the integrity of the skin silhouette and can cause significant cosmetic changes that cannot be hidden by makeup or clothing.
Both men and women can have acne scars. In males, acne scars in the lower pole of the face can be covered or obscured by facial hair. Acne scars of bilateral temples, cheeks, and neck, however, can be difficult to conceal. Females have the option of concealing their acne scars with makeup and foundation, however, any experienced female knows the limitations of makeup in covering the contour irregularities caused by acne scars.
Acne scars can present with several main problems. The scars can be depressed, thickened, irregular, and/or associated with hyperpigmentation or hypopigmentation. Acne scars can also vary in terms of their depth-width ratio and whether they occur as isolated lesions or in clusters. Fortunately, for patients who have acne scars, there are many treatment modalities that can improve scars and make them less noticeable.
Acne scars are most common on the face, shoulders, and back. Acne scars on the chest usually resolve with time, except in cases where a keloid scar develops. Chest keloids that have developed from a previous acne pustule are extremely difficult to treat and are often very aggressive scars. Acne scars on the face, shoulders, and back can develop contour irregularities, hypopigmentation, or hyperpigmentation. Contour irregularities are treated with chemical peels, dermabrasion, acne surgery, and subcision. Hyperpigmented scars are treated with laser, chemical peels, and topical creams. Hypopigmented acne scars are very difficult to treat, as the permanent pigmentary loss is difficult to stimulate.
TYPES OF ACNE SCARS:
Dark Acne Scars: Scar experts often encounter patients who think that they have permanent scars, only to find that the acne scars solely consist of abnormal hyperpigmentation without significant atrophy or hypertrophy. Dark acne scars and spots are caused by an abnormal skin process that is known as post-inflammatory hyperpigmentation, in which the pigment cells of the skin respond to the presence of acne cysts by depositing high amounts of pigment. PIH is a process that may lead to permanent discoloration if treatments are not used to reduce existing pigmentation and prevent the deposition of new pigmentation. Our office is a leading center for the treatment of dark acne scars. These types of scars rarely require surgery or invasive treatments. Patients with dark acne spots, with or without atrophic scars, may benefit from light chemical peels, topical Melarase creams, and Melapads. Our dark spot correction protocol utilizes TCA peels, salicylic acid peels, glycolic acid treatments, and Hydroquinone and non-Hydroquinone skin lighteners. Melapads are a convenient and easy-to-use at-home daily chemical peel to help exfoliate existing dark spots.
Icepick Scars: Acne scars are categorized based on the several different methods. Some acne scars like valley scars, box-car scars, and ice-pick scars are categorized using old nomenclature based on what the scars resembled in every day life. Newer categorization of scars relies more on distinguishing depth to width ratios (DTW). Ice pick scars are very narrow but extremely deep scars that look like they were cored out by a long, sharp ice-pick. They have a narrow width and long depth.
Treatment options for ice-pick scars are limited to a few basic, but highly effective therapies. The most common procedures used to treat ice pick scars include TCA Cross, Fractional CO2 laser, and Ematrix fractional RF. TCA Cross is a popular technique in which a highly concentrated acid known as TCA is delicately applied onto the ice pick scar, causing it to build collagen and close-up over the course of a month. Since the ice-pick scar is so deep, it may take more than one application of TCA Cross on a monthly basis to improve the scar. There is some downtime with the TCA Cross method and patients are advised to use Melarase creams twice daily to the area to prevent any skin discoloration and pigmentation in the skin.
TCA Cross is ideal for ice-pick scars on the nose and cheeks. Once the ice-pick scars are treated completely, our office sometimes recommends laser resurfacing with fractional CO2 laser to help even out contour and blend in the skin.
TREATMENTS FOR ACNE SCARS:
At-home Chemical Peels: Melapads Daily Exfoliating Pads contain 60 pre-soaked alpha and beta hydroxy acid pads that are used to exfoliate the skin and reduce excess sebum, improve skin complexion, and lighten dark spots. Melapads can be used twice daily Chemical peels have many applications in skin rejuvenation and acne scar improvement. Chemical peels vary in terms of the causticity and degree of dermal penetration. The deeper a peel is, the more effect it will have longterm. On the other hand, the deeper a peel is, the more risk there is in developing complications, including discoloration, blistering, and scar. That being said, our office employs chemical peels very often in the management of superficial and deep acne scars.
Glycolic Acid Peels: Alpha hydroxy acid peels can be used alone or in combination with other chemcal peels. An excellent choice would be a alpha-beta hydroxy acid peel that combines salicylic acid with glycolic acid. Concentrations ranging from 30% to 70% are used on the skin to improve skin quality and to reduce abnormal dark spots associated with acne scarring. Much like Salicylic Acid peels, glycolic acid peels have not proven efficacious for deep atrophic acne scars.
Salicylic Acid Peels: Salicylic Acid is one of the most commonly used chemical peels for active acne and for acne scarring. This beta hydroxy acid can help exfoliate skin and remove deeply pigmented acne scars, but is less efficacious for atrophic scarring and indentation of the skin. In our Santa Monica office, we use Salicylic Acid peels on a once weekly to once monthly basis to help reduce active acne, acne pigmentation and dark spots, and to clarify the skin surface to improve complexion and skin quality.
Facial Fillers for Acne Scars:
Hyaluronic Acid facial fillers such as Juvederm, Restylane, Belotero, and Voluma can be used in various degrees to directly fill in areas of atrophic scarring. Belotero is a 'softer' filler that can be injected intradermally to fill-in acne scars, whereas Voluma and Perlane may be less suitable for direct acne scar injection. These volume fillers last from 6 months to two years and can improve acne scars.
- Juvederm: This filler is excellent for volume injection into the soft tissue of the cheeks and the lips. Juvederm is slightly denser than Restylane and can last quite a bit longer. Because Juvederm is thicker than Restylane, it is not always appropriate for acne scars on the skin.
- Restylane: One of the most studied and most popular hyaluronic acid fillers. Restylane injections can be used to plump up deep acne scars and to volumize the skin around areas of acne scarring. Hyaluronic acid is an absorbable filler that can be reversed if necessary. Typical results last six months to one and a half years.
Sculptra and Radiesse are both volumizing facial fillers that can stimulate collagen production and recontour volume loss in the skin and soft tissue. If there is significant volume loss or skin laxity within the cheeks and soft tissue surrounding acne scars, volumizing fillers can be used to add necessary volume to make the skin tighter and more voluminous, thereby helping to correct atrophic scars. Volume loss is a secondary contributor to atrophic acne scars, causing cumulative loss of underlying collagen support in the dermis and skin.
Fat transplantation has many advantages over commercially-available facial fillers such as Juvederm, Restylane, Radiesse, and Belotero in that fat is easily accessible as a donor tissue graft. Fat grafting is used in patients who have volume loss in association with atrophic scars. With volume enhancement, the underlying tissue is made more turgid and tight, resulting in an improvement in the appearance of acne scars. Fat transplantation is rarely used to fill individual acne scars, but rather used to improve deficient volume in the cheeks and soft tissue.
Ematrix uses a well-established and highly effective fractional radiofrequency treatment that is known as sublation. Atrophic acne scars and indented scars respond well to the Ematrix, as the delivered RF energy helps stimulate collagen production and tightening of the skin. If you are considering a treatment for indented acne scars, you may consider Ematrix as a gold-standard in the care of atrophic scars.
Laser Acne Scar Treatment:
The treatment of acne scars with laser has many benefits. Unlike surgery, laser is a non-invasive modality with minimal scarring or downside. The limitations of laser acne scar treatment are due to its inability to selectively stimulate collagen formulation directly underneath broad based scars. Laser acne scar treatment has definite advantages. The key to laser acne scar treatment is choosing the right laser to fit your needs. There are many different laser options for acne scars. Ablative vs. Non-ablative lasers differ in the degree of tissue damage involved. Non-ablative lasers cause less epidermal and dermal tissue damage and are thus limited in terms of activity. In my office, I employ several different lasers for acne scars. The one specific laser that I will discuss in this description is the pulse dye laser. The pulse dye laser, VBeam, is most effective for red and inflamed scars that are noticeable after pustular evacuation.
Punch Excision: The technique of punch excision and punch grafting from deep ice-pick scars are remained a viable option for those patients with deep scarring that has not responded to laser resurfacing or TCA-Cross. In this procedure, a decision is made to harvest a punch graft from a donor site in the back of the ear and then transplant it into the 'punched out' defect from an ice-pick scar. The graft of skin usually incorporates into its host recipient site and receives its blood supply from the new location. Punch excision and grafting is ideal for deep ice-pick scars.
Subcision is a minimally-invasive surgical technique that uses a specialized needle to release tethered acne scars from their attachments. It is thought that some atrophic acne scars are formed because the inflamed acne cyst caused fibrotic attachments between the skin and the underlying skin fascia. These fibrous bands tether scars down, particularly during movement. Subcision attempts to release the scars and 'pop' them up to the surface of the skin. Patients who have undergone subcision also report an increase in collagen and a gradual leveling of the skin surface around a scar.
Some surgeons refer to subcision as 'subcutaneous incision-less surgery' because a small needle can be used to uplift a tethered scar without cutting or incisions. Subcision can be performed multiple times on a single atrophic scar, gradually improving its contour relative to the adjacent skin and soft tissue. Subcision can be utilized on all skin types and has no significant risk of complications.
TCA Cross Technique:
Deep ice-pick scars are found on the face and nose. These scars are characteristically very visible and at the same time, very difficult to treat. Ice-pick scars have a high depth to width ratio and are often very deeply pitted with a narrow base width. They are often conical in shape and can be very visible from far off. Several laser resurfacing treatments have been used to improve ice-pick scars but time and time again, the technique of TCA Cross has proven to be beneficial for the reduction in ice-pick scar visibilty, depth, and contour. TCA Cross uses a highly concentrated form of a caustic cosmetic acid known as trichloroacetic acid. The TCA is carefully applied onto the ice-pick scar, causing it to form collagen and collapse from within. Most patients will need sequential treatments, often numbering one to three, spaced one month apart. TCA Cross can cause some skin discoloration and for this reason, we advise patients to begin Melarase creams prior to treatment.
TCA Cross Chemical Peels are an excellent procedure designed to treat difficult acne scars and enlarged pores that are resistant to standard therapy with chemical peels, fractional laser, and Ematrix. The most common reasons to undergo TCA Cross Chemical Peels is to treat the following types of conditions:
- Ice-pick acne scars on the nose and face. These scars usually have a high Depth to Width ratio.
- Enlarged pores on the nose that are visible from a distance.
- Deep acne scars that are marsupialized or pitted.
- Resistant Acne Scars that have not responded to fractional laser or deep chemical peels