Acne is the most common skin problem faced by patients. The most distressing and severe outcome of acne is acne scarring.
Acne scarring therefore is the most common type of scar that we treat in our practices and requires significant expertise to manage scarring of various types and on a range of skin types.
Different types of acne scars require different types of treatments and this is dictated by the size, shape and depth of the scar. It is also influenced by the skin type and the area on the body that it is involved.
Darker skin types tend to scar more significantly and have more complex scars to deal with, including keloid scarring. When treating darker skin types, there is a significant element of preparation, monitoring, aftercare and expertise with settings that needs to be followed. Otherwise, the risk of worsening scars or leaving patients with pigment problems such as darkening the pigment or pigment loss, can be problematic.
Acne scars remains a significant problem for all skin types and our dermatologists and their team can help you find the best solution for your scarring.
Types of Acne Scars
Classically, we classify acne scars into four different categories, each of which has a range of different treatments that would be appropriate.
Ice Pick Scars
Ice pick scars are like little holes in the ice made by an ice pick. They are deep, narrow and can be visually quite disturbing.
Treatment options for ice pick scars include TCA CROSS (using Trichloracetic acid), ablative laser, fractional laser, radio frequency micro-needling or surgical techniques such as punch excision or punch elevation.
Box Car Scars
A larger version of ice pick scars are box car scars. These can vary in depth to superficial to deep. They are larger in size and often a more angular shape.
Treatments for box car scars is similar to the treatment options for ice pick scars and your specialist dermatologist will be able to advise which treatments will be best for your particular scars.
Rolling Scars
Rolling scars occur due to bands of scar tissue forming beneath the skin and acting as a tether from the surface to the underlying tissue. This results in a rolling and uneven skin surface.
These scars distress patients under downlighting or harsh lighting as they can stand out quite prominently because the angle light throws shadows with the rolling scars. Downlighting will make these types of scars look worse.
It is hard to see where these scars start and end as they are rolling and continuous and over a larger field. Some people refer to the appearance of the skin looking like an unmade bed.
Treatment for rolling scars often combine subcision with other treatments such as laser and injectables. By doing so, we can improve the rolling scars significantly. If subcision is not used for rolling scars, you often will not get the improvement that you are looking for.
Hypertrophic or Keloid Scars.
Hypertrophic or Keloid scars are raised scars which can have sensation to them. People may experience irritation, burning and itching and they may continue to grow in size and extend beyond the borders of the active lesion itself. They can be challenging to treat and usually require multiple sessions of treatment. There is a recurrence rate with these scars.
First line treatment is generally scar softening injections. Dr Manoharan and his team have developed unique combinations of scar softening medications that can be injected into these raised scars to soften, flatten and reduce inflammation.
For resistant keloid and hypertrophic scars, we may use fractional lasers or cryotherapy. If the scars are red we will use vascular lasers to reduce the vascularity in these scars and to modulate their growth.
In certain areas of the body such as the earlobe, we may surgically revise the scar and follow that up with injections and pressure implements.
Acne Scar Treatments
Our specialists have a large range of treatment options that they can combine in different ways to provide you with the best outcomes for your scars. Below, we briefly summarise some of the acne scar treatments that your specialist dermatologist may recommend for you.
TCA CROSS (TriChloroacetic Acid Chemical Reconstruction of Scar Skin)
We often use TCA CROSS treatment to treat ice pick scars. During this treatment the acid is dripped into the scars to cause a controlled burn resulting in scar breakdown and remodelling of skin.
We will often combine TCA CROSS with ablative or fractional lasers, or radio frequency micro needling.
Radio-frequency (RF) micro-needling
We use radio-frequency micro-needling as a useful technique for mild to moderate scarring in all age groups. Particularly suitable for patients who have minimal downtime, this treatment has a relatively quick recovery. It is generally well tolerated and can provide good results for many patients.
It is also useful for patients who have active acne as the radiofrquency micro-needling can also destroy some of the overactive oil glands involved in the acne itself.
This is a useful series of treatments for patients who have some active acne, are of the mild-moderate scarring group and they do not have a lot of recovery time.
It is also useful for younger people who are going to school so are not able to take much time off for recovery.
This is different to light needling techniques that do not penetrate the skin very deeply, and do not include the radio-frequency remodelling. You can read more about RF micro needling here.
Laser Treatments
Fully ablative laser treatment is the most intensive treatment available for acne scarring. You can get significant improvements but there is a longer required downtime; typically 7-10 days recovery should be expected. It also requires more expertise to provide safe, optimal outcomes. This treatment is usually restricted to the face.
Fractional ablative laser treatment is lighter and used for quicker recovery periods, when the scarring is less severe and for scars away from the face.
Fractional non-ablative lasers are a good option when patients have milder scarring, are looking for treatments with minimal downtime and are committed to a series of lower-level treatments that can provide improvements both in terms of the scars and also in terms of the tone and texture of the skin. These devices can also be used as maintenance treatments once a heavy laser resurfacing is completed. After an ablative laser treatment is done, you can have fractional non-ablative laser as your maintenance treatment for ongoing skin health.
These are all techniques used in combination to remodel the scars, break down scar tissue, promote new collagen and normal health skin growth.
Surgery for Acne Scars
Surgical revision and techniques such as punch excision can be helpful to remove some deeper scars, which will neaten the scar before laser resurfacing.
In other instances we will use a surgical technique known as punch elevation where we cut out the scar, lift it up and suture it to the surface of the skin so that the scar is brought back up in line with the level of the rest of the skin surface. We then follow that up with laser resurfacing.
Our dermatologists also use subcision, whereby specialised cutting needles are used to cut through the vertical bands of scar tissue that cause rolling scars.