Multi-faceted approaches repair various acne scars

February 1, 2006

Acne scars can be atrophic or hypertrophic and can vary widely in shape, length, depth and dimension — and one patient can have a variety of scar types.

About 5 percent of patients, however, develop a severe form of acne which can lead to permanent scarring. Luigi Rusciani, M.D., professor and dermatologic surgeon at the Catholic University of the Sacred Heart in Rome, Italy, says there are ways to treat those scars to relieve the patient of social discomfort and the possible loss of self-esteem.

There are both surgical and non-surgical approaches to addressing scarring issues, Dr. Rusciani told a recent meeting of the European Academy of Dermatology and Venereology in London. He says the appropriate approach depends on the type of scars the patient has.

With active acne, prevention is the goal, to keep new scars from developing, he says. Patients with past acne suffer from permanent scars, which can successfully be treated with surgical techniques, he adds.

Types of scarring

Dr. Rusciani says acne scars can be atrophic or hypertrophic and can vary widely in shape, length, depth and dimension - and one patient can have a variety of scar types.

Atrophic acne scars can be shallow and wide boxcar scars, or deep and narrow ice-pick scars.

Appropriate treatments for boxcar scars are filling, peeling, dermabrasion and laser abrasion. Ice-pick scars respond to dermabrasion, laser abrasion, base elevation and transplant, but the best results for more severe scars are often obtained by surgical excision, or in some cases, the surgical lifting of the skin.

Treatment options

Several potential treatments work with a boxcar scar. If it's a small scar, a punch biopsy can remove the scar tissue, and then the area can be closed with a suture - turning a square or circle into a superficial linear scar.

"If the boxcar is big and deep, we can also do an elevation of the base of the scar with a filler or by releasing the scar tissue beneath the base, then we make a suture on the periphery," he says.

Dr. Rusciani continues, "The treatment choice depends on the size of the scar, how deep it is. For the small scar, I prefer to remove it, but with the bigger scar, I prefer base elevation."

For ice-pick scars, Dr. Rusciani prefers surgical removal, then smoothing the area with a resurfacing procedure.

"After the preliminary procedures, it is usually necessary to do a deep or medium deep peel, or resurface the area with a CO2 or erbium laser or dermabrasion. If we only need a superficial action, we can do a medium peel; if we need to go deeper, the laser is usually a better choice," he says.

In performing the chemical peel, Dr. Rusciani says that although a phenol peel is very effective, in patients from the southern regions of Europe, it is not the treatment of choice because it can leave black spots on the darker complexion that is native to the area.

"Of course, the phenol can work well for most American skin types and the northern portion of Europe.For the southern Europeans, the trichloroacetic acid (TCA) peel is generally the better choice," he says.

Hypertrophic scars present a different challenge and can be treated with intralesional infiltration of steroids or with dermabrasion. In the same category, Dr. Rusciani says, keloids can be more difficult to treat because of the possibility they might recur or the lesion may get worse.

If the dermatologist decides to try to improve the scar, he says treatment choices include cryotherapy, intralesional steroids and compression dressings.