Treatments for acne scarring

Ablative fractional lasers, such as the carbon dioxide laser, cause damage to both the dermis and epidermis. This greater degree of damage leads to greater stimulation of wound healing response and can generate more collagen potentially allowing correction of more significant scars. The initial phase of the healing process takes 1-2 weeks and is associated with redness, swelling, blistering and crusting. Redness and pigmentary change can persist for many months and rarely can be permanent.

Non-ablative lasers, such as the Resurfx laser or the ICON laser cause selective damage to the dermis. This is associated with some redness and swelling for a few days following the procedure, however there is generally not blistering, crusting or shedding of the skin and the risk of pigmentary change is low. Non-ablative lasers usually require a course of several treatments.

Scarring caused by deep nodules and cysts can lead to the formation of fibrous bands which tether the skin to deeper tissues causing dipped scars. Subcision is a procedure that will divide these fibrous bands. Subcision is performed with a sharp needle or cannula which is inserted under local anaesthetic through the skin surface and then manipulated to divide fibrous bands beneath the skin surface. It can also be combined with dermal filler injection.

Trichloroacetic (TCA) acid is a chemical which causes inflammation when applied to the surface of the skin. TCA CROSS stands for TCA chemical reconstruction of skin scars. This involves the precise application of small amounts of TCA to the base of atrophic (depressed) acne scars. This triggers the wound healing response which can lead to the depressed scar filling out and becoming less noticeable. Following treatment the area will be inflammed for 5-7 days and can remain a different color for weeks-months. TCA CROSS can be an effective treatment for certain depressed scars where other options - even ablative fractional lasers - do not cause a significant improvement, however it does have some significant risks as discussed below.

Where patients have a relatively small number of small, deep scars (usually ice pick scars) these can be be removed surgically using a punch device. A small, round core of skin is removed under local anaesthetic and one or more stitches are applied. This can heal to give a straight line scar which is usually less noticeable.

Scars that are raised above the level of the skin surface are known as hypertrophic. When scars spread beyond the site of the original acne lesion these are keloid scars. Certain individuals have a tendency to form this type of scar and there is a risk that they can recur despite treatment. Treatment of hypertrophic and keloid scars is challenging since they have a tendency to recur and any interventional procedure or laser treatment carries the risk of triggering new scar formation or worsening existing scarring. Cautious injection of steroid into the scar can help to flatten and reduce the appearance.

Acne lesions can cause redness or pigmentation that can persist for weeks-months after the lesion has resolve. Redness is more common in those with lighter skin types and pigmentation in those with darker skin types. Both will usually resolve without treatment, however laser treatments can speed this process. Redness of the scar is known as 'post-inflammatory erythema' (PIE). It is caused by an increased number of blood vessels in the scar tissue compared to the normal skin. Redness can be improved with vascular laser or intense pulsed light treatments. Darkness of the scar is known as 'post-inflammatory hyperpigmentation' (PIH). It is caused by increased production of pigment due to inflammation in addition to damage to pigment-producing cells 'melanocytes' that causes them to 'fall' from the surface of the dermis to deeper locations where they can persist for many months or years. Whilst it will improve with time topical and laser (Q switched or pico laser) can be helpful.

Microneedling uses fine needles to create tiny punctures in the top layer of the skin, triggering the production of collagen. This increase in collagen can help fill in and reduce the appearance of acne scars. The procedure is relatively inexpensive as it is often performed by non-clinicians. Dr Lynch does not perform this procedure often as laser treatments are generally superior and associated with less risk of complications.

Loss of dermal tissue volume is a particular challenge in treating acne scars. Dermal fillers can be placed either under the surface of the skin to support areas where there had been volume loss or small quantities can be placed within the skin itself. Another option is skin boosters, such as Profhilo which can generally boost skin volume reducing the appearance of scars.

Topical retinoids such as tretinoin and adapalene promote cell turnover and collagen production. This can help to reduce the appearance of scars. It can also be helpful for post-inflammatory hyperpigmentation and mild atrophic scars.