Types Of Scars:

Acne is inflammation in the skin which can leave a variety of skin changes. Early scars are often very red or leave pigment changes in the skin. Deeper acne lesions leave small depressions in the skin – rolling scars- or even large areas of volume loss. Surface changes result in ice pick scars which look like small holes, or larger surface irregularities referred to as box-car scars or surface of the moon scarring.

Some acne results in a sub-surface change called fibrosis. In this case, scar tissue makes thick bands that tether or hold the skin down. Some individuals are prone to thick scarring which creates hypertrophic scars and keloids both of which grow above and below the skin surface.

How we tackle scars by scar type:

Red scars: Red (erythematous) scars are easily treated with a vascular laser such as a pulsed dye laser or KTP laser. We commonly use the Vbeam pulsed dye laser. IPL or intense pulse light can also be used for red acne scars in lighter skin types and has the additional benefit of treating pigment or color changes.

Color changes: Brown or dark marks (hyperpigmentation or PIH for post-inflammatory hyperpigmentation) left by acne can be treated with topical creams and chemical peels that also help acne. Device treatments that help lighten brown spots include lasers specific for pigment: long pulse alexandrite laser, GentleLase, and the q-switched 1064 which is ideal for darker skin tones. Non-ablative fractional treatment and ablative fractional treatment also help lift pigment via microscopic impacts on the skin that lift pigment as they heal.

These device include the 1927 nm fractional laser (Ultra laser), the 1550 nm fractional laser (Fraxel Dual) and the fractional ablative CO2 laser. Other fractional devices can help pigment and include microneedling, microneedling with radiofrequency (Infini Genius), microablative radiofrequency (Viva) and thermomechanical fractional heating (Tixel).

Depressions: Rolling or depressed scars often are not visible except with down or angled lighting. They represent areas where the sub layers of skin – dermis and subcutaneous layer – were damaged by inflammation of acne and have lost collagen, elastin and the matrix that supports the skin. All of our devices employed in the treatment of acne scars have the ability to stimulate renewal of these layers with stimulation of collagen, elastin and dermal matrix.

This process takes time – collagen stimulation occurs over 3-9 months. Skin care products that help the skin renew will be suggested as part of your regimen (See “Products that help your skin respond to acne scar treatments” below). If tethering or bound-down scars are noted – scars that are bound or adhered to the upper layer of skin by fibrous bands – then a procedure called subcision will be recommended and can be essential to the success of your treatment. (See “Tethered or bound-down scars”)

Tethered or bound-down scars: Tethering occurs when healing from deep inflammation of acne results in fibrous bands forming from the deep tissue to the surface of the skin. I liken these bands to ropes holding something down – like ropes tethering a hot air balloon to keep it from floating away. These fibrous bands must be released for improvement to be seen in these types of acne scars. This is done with a procedure called subcision. This involves using a needle with a triangular or spade like tip that is inserted under the skin and moved back and forth to break up and release these bands.

Vertical Scar Bands

Like Ropes On A Hot Air Balloon

Thick scars: In some individuals, acne scarring results in very thick scar tissue to form that extends down into the skin and often above it. This is hypertrophic scarring. Keloid scarring is scarring that is also thick but grows beyond the area of the injury. These scars are treated with injections and ablative fractional laser treatments.

Volume loss: Areas of more severe acne or acne related inflammation often leave deeper defects in the dermal and subcutaneous layer These defects are too large to be corrected by collagen stimulation from laser or energy devices and require dermal filler injections. This filler can be a volume filler, a collagen stimulatory filler (biostimulatory filler) or a combination of both.

Ice pick scars: Surface marks that look like large pores or holes and resemble marks that would be left by an ice pick can be addressed with a procedure called CROSS. CROSS stands for Chemical Reconstruction of Skin Scars. A very concentrated (90%-100%) Trichoracetic acid (TCA) is applied to deeper pitted scars using a small wooden applicator – typically the end of a toothpick. This deep application of TCA to the base of the scarring will help to promote deep dermal collagen production.

Wider surface scars sometimes called boxcar scars: Larger scars that involve the surface of the skin often best benefit from a treatment that affects the skin surface over a larger area than is affected by small needles or microscopic impacts. These treatments include Viva microablative radiofrequency treatments, fractional ablative laser and fully ablative erbium laser.

The ablative and fully ablative laser treatments have a significant risk of causing skin darkening after treatment in darker skin types so the Viva treatment is preferred. The other devices also impact the surface but in a small surface area so may be slightly less effective for the box car scars.

Number of Treatments:

The number of treatments recommended can vary depending on the type and severity of scars, as well as the chosen treatment approach.
Typically, patients will need multiple sessions, with anywhere from 4-12 of the recommended treatment plan. These sessions are usually scheduled 4-6 weeks apart. Consistency and patience are key, as results often become more apparent over several months.

Products that help your skin respond to acne scar treatments: To optimize your skin’s response to acne scar treatments, it is important to consider incorporating the following a growth factor into your skincare regimen-

• Daily SPF: Elta Clear SPF 46

• Growth Factors: Growth factors stimulate and support rebuilding
and repair of skin structures like collagen and elastin daily as well as
post procedure.

• FactorFive Regenerative Serum, Neocutis Bio Serum