Acne scars affect patients’ self-esteem and self-confidence long after their acne breakouts have cleared. The frustration for practitioners and patients alike is that there have traditionally been few effective treatments to eradicate the deep scars of acne. While there remains no single treatment modality that can completely erase the textural and pigmentary changes experienced by patients, physicians are achieving improved outcomes through the use of lasers, peels and fillers in combination with more invasive options, like subcision and punch grafts.
“Acne and acne scarring are extremely emotional conditions,” says Vic Narurkar, MD, director and founder of the Bay Area Laser Institute in San Francisco. “While I do many things in my practice, the happiest patients are the ones for whom we improved their acne scarring. It is life changing.”
One of the most challenging aspects of acne scar treatment is that there is no one-size-fits-all solution. Since scars come in multiple forms—rolling, boxcar, ice pick and pigmented— physicians must create a customized regimen that best matches the individual patient’s needs, says Ruth Tedaldi, MD, founding partner of Dermatology Partners in Wellesley, Massachusetts.
The key to achieving high patient satisfaction is to set realistic expectations and avoid over-promising and underdelivering. “Patients should not expect removal of the acne scar, but improvement in the appearance of the scar,” says Dr. Tedaldi. “With today’s treatments, the topography of the skin becomes much less angulated and simple camouflage with makeup becomes easier.”
The topographic depressions of acne scars are the result of compromised collagen production, formed during the natural wound healing process. The perpendicular bundles of collagen created during active acne breakouts anchor the skin of the scars down.
“The majority of patients have atrophic or ice-pick scars,” says Jill S. Waibel, MD, a dermatologist at Miami Dermatology & Laser Institute. “Both of these types of scars result from loss of collagen deposition during the wound healing process of acneiform lesions.”
Superficial approaches, used to increase collagen production and tighten skin, include glycolic acid chemical peels as well as topical tretinoin and topical hydroquinone for skin surface improvement and pigmentary variation. But these approaches have limited success, says Dr. Waibel.
Laser Skin Resurfacing
Fractional lasers—both ablative and nonablative—have built on the limited success of chemical peels. Both devices are used to stimulate collagen production, which helps to replace scar tissue with more normal collagen, and tighten the skin to reduce the depth of acne scars.
Murad Alam, MD, professor and director of cosmetic dermatology at Northwestern University in Chicago, prefers nonablative fractional resurfacing. He admits his practice is conservative when it comes to laser resurfacing: Densities and energy levels are gradually increased, and at least six treatments are usually delivered over a comparable number of months.
“You have to make sure the aggressiveness of the procedure is coincident with the patient’s lifestyle,” he says. “In general, it is easier for people to hide out for several individual weekends, as with nonablative devices, than for two weeks continuously, as with ablation.”
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