Acne can be bad enough on its own, but the scars it leaves can last a lifetime. One of the many great things about being a dermatologist is being able to make a difference in my patients’ quality of life by treating their skin diseases and also addressing the after-effects of those conditions. Scarring can have a dramatic effect on self-esteem, so treatment can, conversely, be life-changing. Though I can’t make your skin look completely undamaged, a lot can be done to reverse the damage caused by the onset of inflammation produced by acne. These treatments can improve the texture, tone, and overall appearance of the skin. There are many ways to address scarring, depending on location, type, color, and skin type, among other factors. Below I have outlined some of the ways I treat acne scarring to bring about smoother and more evenly toned skin.
Several topical medications and treatments can help even out discoloration and encourage collagen formation to reduce the appearance of scarring. From topical retinoids to silicone creams, I incorporate topical medications into all of my acne scar treatment protocols. If the scarring is very mild or occurred recently, and I am also treating active acne, a topical retinoid is typically a vital part of the regimen. These power-house Vitamin A derivatives help treat current acne, reduce/prevent future outbreaks, smooth fine lines and wrinkles, and boost collagen formation. For those who cannot tolerate retinoids or have other aspects of their acne that require different approaches, I also use azelaic acid, lightening agents, alpha and beta hydroxy acids, and other topicals. Sun protection is a crucial part of acne scar treatment as sun exposure can lead to uneven pigmentation, some acne scar treatments can cause temporary sun sensitivity, and as your skin needs an optimal environment to heal after procedures to treat acne scarring.
I could (and probably will) write an entire blog on chemical peels. Chemical peels—like many acne scar treatments—cause controlled damage to the skin. Your skin then heals with the goal of your newly formed skin being smoother and more evenly toned. Peels can be superficial, medium, or deep. I do superficial and medium-depth peels. Deep chemical peels are quite aggressive, typically unsafe in darker skin, and can require cardiac monitoring. I most commonly do salicylic acid peels as they are safe across all skin colors/types, are easily titrated for more aggressive treatment if needed and are used on virtually any area of skin. Most of the time I treat active acne first and then address scarring once the acne is under control. However, salicylic acid peels have the advantage of treating active acne, discoloration, and scarring simultaneously. I typically perform a series of 3-6 peels—one every 4-6 weeks—and then reassess. Peels are generally for mild scarring and discoloration. Deeper or more extensive scars tend to need more aggressive treatments.
When scars form, there can be a fibrous band that causes a depression in the surface of the skin. Depending on factors such as depth, location, size and shape, depressed scars can often be treated with subcision. The process involves me numbing the affected skin, using a specially shaped needle adjacent to the scar and orienting it to free up the fibrous scarring in the dermis that is binding down the skin and causing the visible depression. Immediately afterward, I inject the treated site with an agent of my choice (saline, filler, plasma) to occupy the dead space just created and to encourage the formation of new collagen that does not draw the skin down. Subcision generally requires multiple treatments.
Intense Pulse Light (IPL)
IPL is a broad spectrum of light in the visible to the near-infrared portion of the electromagnetic spectrum used to selectively reach targets in the skin and eliminate/lessen those targets. The most common concerns I address with IPL are redness, blood vessels, brown spots from sun damage, and pigmented (non-white/non-blonde) hair, but improvements in wrinkles and pore size are also possible. Utility for scarring is generally limited to reducing the associated darker discoloration, redness, and blood vessels. The number of IPLs needed is variable but typically falls between 3-6 monthly sessions.
Platelet Rich Fibrin Matrix (PRFM)
At the time of this blog, my office is the only practice in Tulsa offering PRFM. I imagine I’ll write a more detailed blog on it in the future, but PRFM is an exciting treatment that I use to address a variety of dermatologic issues from hair loss, to scarring, to skin aging. Many readers have heard of platelet-rich plasma or PRP. PRP involves withdrawing blood, spinning it down, and separating the platelets and plasma from the rest of the blood. We inject the PRP into the skin, and platelet-derived growth factors are released into the treated area. With PRFM, the platelets and plasma are suspended in a fibrin matrix that remains in place over hours to days for prolonged release of growth factors and longer stimulation of collagen. For acne scars, PRFM is usually combined with subcision, microneedling, or laser resurfacing. The PRFM aspect of treatment is used anywhere from 1-4 or more sessions.
As an aside, you may have seen the recent report of possible HIV transmission from PRP treatments at a New Mexico spa. Possible HIV transmission is just one of the many reasons to ensure you see a board-certified dermatologist (American Board of Dermatology or National Board of Physicians and Surgeons [in Dermatology]). PRP and PRFM can be done safely and effectively in the right hands. In our office, we utilize a locking closed PRFM system. From drawing blood to injection—every step is done in the room with the patient, and I only treat one patient with PRFM at a time.
Microneedling is a great way to stimulate new and improved collagen formation. The skin is numbed, and then a microneedling (aka microchanneling) device is used to make controlled pinpoint punctures into the skin. As you heal, new smoother skin is formed. Though the skin looks back to normal within an average of one to three days, the effects of the treatment accumulate and become visible over several months. For acne scarring, I sometimes combined microneedling with subcision. Immediately after microneedling, I typically apply a growth factor serum or PRFM topically to boost the collagen-building effect of the treatments. Depending on the scarring, I usually recommend 3-6 monthly treatments with reassessment 3-6 months after the last treatment.
Like microneedling, laser resurfacing can utilize the process of wound healing to reduce the appearance of acne scars. I use a fractional resurfacing laser to induce micro-zones of damage that are then allowed to heal with more even texture and tone. As with other modalities, this may be combined with subcision, PRFM, or growth factor serum. IPL immediately followed by laser resurfacing is an excellent option for scars that are red due to the presence of blood vessels.
So now you know—there are many options in my dermatologic tool chest to address not only acne scars but also many types of scars.
Here is one thing I tell patients: it is critical for your skin to be in good shape before treatment in order to optimize results. Some important things you can do to maximize treatment outcomes:
- Use sun protection daily at least 30 days before and after scar treatment procedures.
- Follow my pre-treatment skin care regimen customized specifically for your skin.
- Follow our instructions for how to care for skin AFTER your procedure(s) as well.
- Don’t smoke. If this is not feasible, try stopping shortly before and shortly after your procedure.
- Let us know if you get a cold sore shortly before treatment. Certain treatments must be postponed when a cold sore is present anywhere on the face.
If your acne scars bother you, give us a call at 918-340-6539 to book an appointment for me to develop a customized plan for you.
Kesha Buster, MD FAAD (board-certified dermatologist)