Acne scarring, a permanent and largely avoidable complication of acne, and most often is a source of significant psychological distress. The prevalence of post-acne scarring is in the region of 10-14% in the general population.
Acne scars are either hypertrophic or atrophic, depending upon whether they are elevated or depressed in relation to the skin surface. Depending on the shape and depth, the atrophic scars are divided into the following main morphological types: ice-pick pitted scars, superficial or deep boxcar scars, and rolling scars. The majority of people have a mixture of these types of acne scars.
- Rolling Scars – These are the most common type of acne scar. Shallow and wide, they have sloped edges, which gives them their “rolling” appearance. They are commonly found on the cheeks.
- Boxcar Scars – These scars appear angular with distinct, sharp-looking edges. This type of acne scars resembles chicken pox scars and can generally be found on the cheeks and temples of the face. Boxcars can be shallow or deep in appearance.
- Ice Pick Scars – These scars are formed as deep pits on the surface of the skin that are commonly narrow in width and extend deep into the skin, appearing like “holes”. Ice-pick scars are usually the most challenging scars to improve, related to their depth.
- Hypertrophic Scars – are less common forms of acne scarring. However, they can occur anywhere on the body. Hypertrophic scars are caused by aggressive forms of cystic acne that cause deep structural damage to the skin and can create unevenness on the surface of the skin by appearing raised and lumpy.
- Hyperpigmentation Scars – Hyperpigmentation commonly occurs on darker-skinned individuals. These scars are usually flat red or dark marks on the skin after the pimple has healed. These dark marks can take months or even years to fade away and can become darker with chronic sun exposure.
Types of Scar: Ice Pick, Box, Rolling, Hypertrophic Scar
The treatment for acne scarring is started by an initial thorough medical consultation and assessment with Dr Ed Omarjee. This allows your skin to be critically examined to determine the types of acne scars you may have and also determine the most appropriate treatment plan to be utilized to improve your acne scars.
Types of Treatments
Fotona Dynamis SP- Erbium 2940nm Laser (Ablative Laser)
The Fotona Dynamis SP- Erbium 2940nm laser works to remove the top layers of skin (epidermis and dermis). The best-available lasers work at a gentle and optimal depth to resurface the acne-scarred skin. This improves skin texture and tone as the laser gently vaporises thin layers of the scarred surface to reveal healthy, undamaged skin below. This induces the body to heal the laser injury, and doing so produces new collagen and elastic tissue as well as locally tighten the skin, and improve the overall texture and tone of the treated skin.
The skin resurfacing by the Fotona Erbium laser can function in a full ablative mode (remove 100% micron-thin layers of skin surface) or in a fractionated mode (the novel F-runner handpiece), where only a fraction of the affected skin is treated in a ablative fashion, leaving intervening areas of skin unharmed. These untreated areas help in rapid re-epithelization of the skin (i.e. healing), reducing the recovery time post treatment and also side effects compared to full field erbium resurfacing.
The downtime post ablative laser treatment varies on the intensity of the settings which is dependent on the degree of acne scars present and also other patient factors. Topical anaesthetic is applied 1 hour prior to treatment to reduce discomfort (and sometimes local anaesthetic nerve blocks maybe required also). This ablative laser treatment can be associated with Medicare refunds if your scars meet Medicare eligibility rules.
Fraxel 1550nm Laser (Non-Ablative laser)
Fraxel laser treatment applies fractional photothermolysis technology to target and treat acne scarred skin tissue, using microscopic laser beams to accelerate the production of collagen within the skin, in a non-ablative fashion. The surrounding skin tissue remains unaffected by the Fraxel laser, which aids in the skin’s ability to heal quicker and grow new skin cells from the inside out.
The subcision treatment utilizes a small needle or cannulae to be placed under the skin and guided beneath the scars of concern, with the aim to release the fibrous tissues. This area over time heals with the deposition of new collagen and connective tissue which aids to push the base of the acne scar upwards.
Scar subcision ideally is suited to shallow, rather than on ice pick scars. Most patients require more than one treatment/visit, but you usually see improvements in your acne scars after each treatment. Subcision can cause local bruising and mild swelling that can last 1-2 weeks. Occasionally some numbness can be felt around the area for a short period also.
Dermal fillers are a temporary measure of treating acne scars and are used in much the same way as they are for minimising the appearance of wrinkles. Once the filler is injected into the treated area, it begins to fill the depressions left in the skin. Dermal fillers can last anywhere from 3 months to a year. Most people need regular treatments to maintain the effect of dermal fillers for acne scars.
Skin Needling (Dermapen/MDerma)
Skin needling involves the use of a specialised electronic needling pen, for example, Mderma or Dermapen to create tiny punctures of various sizes in the treated area of the skin. These punctures facilitate the faster generation of collagen in the skin, which helps to fill acne scars. Unlike some procedures which can affect the top layer of tissue, skin needling penetrates deeper to avoid damaging the surface layer.(for example, up to 2.5mm deep). Skin needling can be used on all skin types. It usually has a short downtime of 1-2 days. Best results are achieved with multiple treatments, spaced 2-4 weeks apart.
This is the chemical reconstruction of skin scars (CROSS) using trichloroacetic acid (TCA). It involves placing very small quantities of high concentration TCA (70-100%) onto the surface of atrophic scars (especially ice pick scars). This causes a localized injury, stimulating an inflammatory reaction, leading to new collagen fibres being produced at this site. The end aim is improve the depressed scar appearance. Multiple treatments are required.
PRP (Platelet rich Plasma) is autologous blood derived treatment. It consists of plasma and platelets. Platelets are key factors in hard and soft tissue repair mechanisms. They provide essential growth factors (such as FGF, PDGF, TGF-ß, EGF, VEGF, IGF) which are involved in stem cell migration, differentiation and proliferation. Additionally,platelets also stimulate fibroblasts and endothelial cells to induce new extracellular matrix deposition (including collagen production) and neo-vascularisation respectively.
Plasma contains many factors essential for cell survival including nutrients, vitamins, hormones, electrolytes, growth factors (such as IGF and HGF), and proteins. Among the plasma proteins, the molecules vital for the coagulation process and for the fibrin polymer formation will serve as a scaffold for cell migration and new tissue generation.
These growth factors and plasma cells can augment the scar treatment process and also accelerate recovery with combination with laser, radiofrequency and subcision treatments.
Laser genesis works in a couple of ways to minimise the effects of acne scarring. The first approach is to reduce the redness and the appearance of scarring by breaking down the blood vessels in the affected area using laser technology. The second approach is to promote the generation of healthy collagen, which in turn promotes rapid healing.
This treatment is usually only utilized once the depressed scars have improved. Laser Genesis can improve skin colour imperfections of the scar tissue and also improve the overall texture of the skin overlying the scar and also surrounding it. Regular treatments are required for optimal results. This is a very comfortable treatment, with no downtime.
Punch excision is a specialised excision method to usually treat a specific type of acne scarring called ice pick scars. Acne scarring can present in different forms, such as rolling, boxcar, and ice pick subtypes. Ice pick scars are a variant that present with very narrow but deep openings and can affect any part of the face but commonly found in the cheeks and temples. Ice pick acne scars tend to be challenging scars to treat with standard options (eg. Laser, Radiofrequency) but punch excision can be an effective method for many of these scars.
Punch excision is a technique using a specific tool that is often used for taking a sample of the skin which is a procedure called biopsy. The tool is called a punch biopsy tool and is a circular sharp apple core-like tool which excises (meaning cut out) the deep ice pick scar under local anaesthetic injection. The subsequent very small wound (usually 2 to 3 mm in diameter) will then be closed with very fine suturing. These sutures are usually removed after 7 days. The aim of this treatment is to convert a narrow and deep acne scar to a fine superficial surgical scar. If needed superficial Erbium laser treatment can be used to improve this new scar.
To learn which type of treatment is best suited to your type of acne scarring, make an appointment with The DOC Clinic today.
The DOC Clinic is a private specialist clinic. Fees charged are in line with AMA recommended rates for specialist consultations. The fee may vary according to the service provided to you on the day you are seen. We require full payment on the day of consultation, and accept cash, EFTPOS, Visa and MasterCard.
Some consultations and/or treatments may attract a Medicare rebate. The DOC Clinic can process Medicare claims at the time of your appointment in the clinic.
Medicare rebates may be available for some acne scarring consultations and/or treatments. Please contact us to find out more.