Acne Scar Removal
How Common Are Acne Scars?
Acne is one of the most common inflammatory skin conditions globally. It is the 8th most common disease to affect individuals worldwide. Despite affecting more than 85% of adolescents, acne may persists well into adulthood. Adult-onset acne variant on the other hand, tends to be challenging to treat as it tends to be more persistent.
Acne scarring is one of the most distressing consequence of acne. Acne scarring affects more than 90% of acne sufferers, and about 30% of cases are classified as severe. The effects of acne scarring pervades across one’s psychological well-being, social life, academic performance and employment opportunities. Hence, effective treatments to prevent and reduce the appearance of acne scars are always part of your treatment plan.
While it is of interest to the individuals to receive early treatment for their acne breakouts, they should also be aware of the acne scar treatments available at the moment.
What Causes Acne Scars?
Inflammation as a consequence of acne drives a modified wound healing response within the skin. This disparity between collagen breakdown and collagen synthesis contributes to the type of acne scars you would have. Acne that is more severe and prolonged will lead to more severe acne scar formation.
When there is more collagen breakdown than synthesis, atrophic acne scars will be more apparent. On the other hand, over-synthesis of collagen will result in more hypertrophic or keloid scarring.
What Are The Types of Acne Scars?
Acne scar types are classified into 2 broad categories, atrophic and hypertrophic/keloid scars. While atrophic acne scars make up more than 80% of cases of acne scars, the hypertrophic and keloidal scars variants are commonly encountered in our local population.
Atrophic scars are subdivided into ice pick, rolling and boxcar scars. Amongst the atrophic acne scars subtypes, ice pick scars are most common (60-70%), followed by boxcar scars (20-30%) and rolling scars (15-25%).
Acne scars are also graded based on their colour; whether red (erythema), brown (hyperpigmentation) or white (hypopigmentation). The degree by how much the scar appears to flatten when you stretch the skin gives some indication to the depth of your scar.
In practice, most individuals would have a mixture of the different scar types, scar depths and scar colour. The treatment objective would be to identify the predominant scar type so that the most suitable treatments can be recommended.
A skin analysis under direct and indirect lighting will determine the acne scar type, acne scar grade and depth. A careful examination personalises your treatment plan based of your unique acne scar type and skin condition.
The planning stage involves discussing acne scar treatment options based on your acne scar type during consultation. The treatment plan is customised with detailed discussion on treatment benefits, downtime and side effects.
The treatment stage involves treating your acne scar subtypes with evidence based procedures. These can range from TCA CROSS, subcision, fractional resurfacing lasers and RF microneedling devices.
Approach to Acne Scars Removal
Every individual is unique, and so will be the acne scar type and distribution. There is no standardised treatment for your acne scars. The acne scars treatment is a dynamic process because the response to treatment, scar types, previous treatments, skin type/condition and downtime greatly differs across individuals.
What has been agreed on a recent international consensus on acne scars, is that a combined treatment approach to tackle mixed acne scarring will yield better results.
The numerous types of acne scar treatment can itself be confusing. Indeed, acne scar revision can be a complex process as often you have more than 2 different scar types requiring different treatments. There is no single method to treat the various scar types. For example, fractional ablative lasers such as CO2 laser will not improve deep ice pick scars and tethered scars very much. On the other hand, surgical procedures like subcision is not suitable for superficial boxcar and rolling scars.
Generally, we treat deep acne scars first to detach the underlying fibrous tissue, stimulate collagen and enhance dermal remodelling before performing a full face fractional resurfacing to even out the skin tone and texture.
The treatment options will also have to depend on your skin type and colour. Individuals with a darker skin tone will benefit from gentler treatments over time, as there is an increased risk of pigmentation with overly aggressive treatments.
Types of Acne Scars Removal Treatment
Pico Laser For Hyperpigmentation
- Post-inflammatory hyperpigmentation (PIH) post acne is common in individuals with darker phototype skin.
- Pico second laser breaks down pigments into smaller fragments which are absorbed naturally by your body.
- Pico-second laser reduces the appearance of PIH safely in all skin types.
Acne Scars Case Examples:
Mixed Atrophic Acne Scars (Grade 3-4)
- TCA CROSS for deep ice pick scars
- Subcision for selected deep rolling scars
- Fractional resurfacing
- Fillers or Rejuran S to augment effects after fractional resurfacing
Mixed Atrophic Acne Scars (Grade 4)
- Subcision of deep tethered scars should be done first to release the deep scars
- Fractional resurfacing
- Fillers or Rejuran S should be done 4 weeks after fractional resurfacing
Mild Acne Scars with Hyperpigmentation
- Pico laser to reduce post-inflammatory hyperpigmentation first.
- Fractional resurfacing with Pico-second laser, INFINI, Genius treatments are safer to minimize epidermal damage for individuals with darker skin phototypes.
Can My Acne Scars Be Treated While On Oral Isotrenoin?
For many years, it was the view that actively treating acne scars whilst on oral isotretinoin could lead to abnormal scarring and poor wound healing. Individuals were told to wait at least 6 to 12 months before starting acne scar procedures. This led to delays in initiating acne scars treatment and prolonging the negative physical, emotional and social implications associated with acne scars.
However, an expert consensus in 2017 found that it was not necessary to halt all forms of acne scars treatment.
Treatments that are not recommended to be carried out while on oral isotretinoin or shortly after completely oral isotretinoin therapy include:
- Mechanical dermabrasion
- Fully Ablative Laser
Treatments that do not have compelling evidence to support delaying treatment and may indeed be safely carried out include:
- Manual dermabrasion
- Superficial chemical peels
- Fractional ablative lasers
- Fractional non-ablative lasers
- Laser hair removal
- Skin surgery
Can My Acne Scars Be Treated While Having Acne?
Individuals who have active acne are at an increased risk of developing acne scars and early intervention is recommended. Individuals with moderately-severe Acne Vulgaris who are often on oral and topical medications may consider acne scars treatment to reduce inflammation, reduce scarring potential and increase the effectiveness of the acne medication.
Various laser and energy based devices may be used concurrently and safely to prevent further scarring and enhance the effects of acne medication. These may include Pulsed Dye Lasers, Nd:YAG Lasers, Fractional ablative and non-ablative lasers and Fractional RF microneedling. Fractional RF microneedling treatment such as the INFINI and Genius have been found to reduce acne lesions and sebum production and improve the appearance of acne scars.
What is the downtime from Acne Scar Removal Program?
This depends on the type of treatments, your skin type and individual healing times. While some treatments such as fillers have very little downtime, some are associated with more significant social downtime, which requires treatment to be planned in advance to suit your schedule.
With the focus on efficacy and safety, we seek to offer treatments planned around your schedule, fitting with your recovery and lifestyle.
- Dermal Fillers: Usually minimal downtimes. Mild swelling post fillers for 2-3 days. Bruising is usually mild and fades in 1-2 weeks.
- Subcision: Redness and swelling lasts a few days, bruising may take at least 1-2 weeks to subside.
- TCA CROSS: Redness and swelling lasts a few days, scabs will typically fall off within a week.
- Fractional Resurfacing (Pico, Genius, INFINI) : Redness and swelling lasts 2-3 days. Most individuals heal within 5-7 days. Downtime is longer with more intense treatment parameters.
Acne Scar Revision
- Monstrey S, Middelkoop E, Vranckx JJ, Bassetto F, Ziegler UE, Meaume S, et al. Updated scar management practical guidelines: non-invasive and invasive measures. J Plast Reconstr Aesthet Surg. 2014 Aug. 67(8):1017-25.
- Gold MH, McGuire M, Mustoe TA, Pusic A, Sachdev M, Waibel J, et al. Updated international clinical recommendations on scar management: part 2–algorithms for scar prevention and treatment. Dermatol Surg. 2014 Aug. 40(8):825-31.
- Alster TS, Lupton JR. Nonablative cutaneous remodeling using radiofrequency devices. Clin Dermatol. Sep-Oct 2007. 25(5):487-91.
- Energy-based devices for the treatment of Acne Scars: 2022 International consensus recommendations. Lasers Surg Med. 2022; 54: 10– 26. doi:10.1002/lsm.23484 , , , , , , et al.
- Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and review of treatment options. J Am Acad Dermatol. 2001;45:109–17.
- Spring LK, Krakowski AC, Alam M, et al. Isotretinoin and Timing of Procedural Interventions: A Systematic Review With Consensus Recommendations. JAMA Dermatol. 2017;153(8):802–809.
- Zeng R, Liu Y, Zhao W, Yang Y, Wu Q, Li M, et al. A split‐face comparison of a fractional microneedle radiofrequency device and fractional radiofrequency therapy for moderate to severe acne vulgaris. J Cosmet Dermatol. 2020;19(10):2566–71.