Different types of acne scars may require combinations of treatments and multiple sessions.
Treating acne scars is rarely an easy fix. Often, dermatologists and their patients are faced with different types of acne scars, requiring what might be combinations of treatments and multiple sessions. With the right treatment approach and by preparing patients for what might be a lengthy process, dermatologists can achieve good outcomes for the majority of patients with acne scars, according to Jennifer Chwalek, M.D., dermatologist, a clinical instructor of dermatology at Mount Sinai Medical Center, New York City.
“I think the most important thing when approaching acne scars is to pay attention to scar morphology,” Dr. Chwalek says.
Classified by shape and depth, acne scars can fall into different categories. Boxcar scars tend to be more depressed and square-shaped. Icepick scars have a narrower apex and a wider opening on the top of the skin. Then, there are atrophic scars and rolling scars. And, less frequently, patients develop keloids or hypertrophic scars.
“Patients presenting with acne scarring often will have mixed scar morphology, which is significant because some treatments treat certain types of scars better than others,” she says. The shape of each scar is the key to effective treatment.
Dr. Chwalek approaches mild acne scarring from shallow boxcar scars with fractionated lasers-either ablative or nonablative. Laser treatments, which help to stimulate collagen to create scar remodeling, might be all that’s needed to get good results in milder cases, she said.
Dermatologists should prepare patients by telling them that treatment, depending on scar severity, might require multiple sessions with the laser. Results occur with time and can take weeks, even months, to notice. And it could be months or as much as a year before acne scar treatment is complete.
“In terms of deciding whether to treat with an ablative or nonablative laser, it really has to do with severity of the scars but also patient preference. There’s definitely more downtime with ablative resurfacing, and there’s more postop care. Patients have to be willing to follow that,” she said. “Nonablative treatments can be used successfully, but oftentimes require more treatments.”
Icepick scars are among the most challenging scar forms that dermatologists treat because they often are deeper and out of reach of current laser treatments.
Dr. Chwalek might turn, instead, to punch excisions or the CROSS (chemical reconstruction of skin scars) method. The CROSS method involves a high concentration of trichloracetic acid, TCA, and using a sharp-tipped wooden applicator to gently drop a tiny bit of the acid into the scar. The result is a localized peel effect that stimulates collagen.
“The nice thing about this method is it’s relatively cheap, and it’s something that a lot of doctors have in their offices,” Dr. Chwalek says. “The downside is you really need to make sure that you’re using something sharp, and you’re limiting the application of the acid just to the scar. Because if it goes outside of the scar, it basically will create a little ulceration or crusted spot in that area, and might even widen the scar a little bit.”
Downtime also is a downside to the CROSS method, as patients can have crusted pock marks on their faces for a week or longer. Patients might need multiple treatments.
Dr. Chwalek says that the CROSS method is “best reserved for the icepick scars that don’t respond to other modalities such as laser.”
Dr. Chwalek often combines a filler with another modality to address difficult-to-treat deeper atrophic or rolling scars.
“I might use a combination of sub-scission to loosen up any adhesions underneath the scar. Then, I’ll add small aliquots of Sculptra to stimulate collagen,” she says.
Usually, when Dr. Chwalek sees keloids or hypertrophic scars related to acne, the scarring is along the jawline or on the chest and back. Her tried-and-true approach involves treating the scar with intralesional Kenalog (triamcinolone acetonide). Sometimes, she’ll use a combination of Kenalog (Sigma-Aldrich, Inc.) with 5-fluorouracil (5FU).
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“I think the injections are the best way to go,” Dr. Chwalek says. “Then, if they are more erythematous, you can treat them with the laser. You just have to be very cautious in these individuals, because of the risk of stimulating scar tissue if you are overly aggressive with lasers.”
Dr. Chwalek says the biggest misconception she sees, mostly among patients, is their acne scars can be treated with microdermabrasion or light chemical peels. Those treatments don’t penetrate deeply enough to notably diminish the scarring, she said.
There are technologies being studied to treat acne scars. One is the picosecond laser, initially developed to treat tattoos. Studies for acne scars are showing promise, according to Dr. Chwalek.
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Other interesting investigational areas including the use of platelet-rich plasma (PRP) or topicals or injectables with growth factors, according to Dr. Chwalek.
Dr. Chwalek has no relevant disclosures.