Treatments for acne scarring

Scarring left behind from old acne can be quite distressing. Thankfully, there are a wide variety of treatment options available for it. The ideal treatment for a scar will vary based on the type, duration and severity of scars. 

In case of any injury to the skin such as acne, the skin may react by either losing collagen giving rise to pits or depressions in the skin (called atrophic scarring) or it may react by producing excess abnormal collagen given rise to thick scars (called hypertrophic scarring).

The three main types of atrophic scarring are:

1. Ice-pick scars: These are v-shaped depressions in the skin that look like ‘pits’ on the surface. Think of ice-pick scars as a cone-shaped dent into the skin.

2. Box scars: these have vertical edges, creating a box-shaped depression in the skin.

3. Rolling scars: these have some collagen tissue tethered to the base, giving the base of the scar an uneven or undulating appearance.

For atrophic scarring, the aim of treatment is to increase collagen production that can fill the depressed defect in the skin, raising the scar to the level of the surrounding normal skin. 

In the recent years, there has been an increase in the range of treatment options available for acne scarring. Lasers and other energy-based devices have become popular.

1. CO2 laser:

The fractional CO2 laser with a wavelength of 10,600 nm is one of the best treatments for atrophic acne scarring. It acts by creating microthermal zones (MTZs) of destruction in the skin, which is basically a controlled form of injury. This stimulates the skin to produce more collagen, thereby covering the defect present in atrophic scars.

There is some downtime associated with it, redness and swelling can take 7-10 days to settle, the healing process requires re-epithelialization and there can be partial “sloughing” of dead skin. 

2. Fractionated microneedling radiofrequency: 

Delivery of radiofrequency energy via microneedles is termed as microneedling radiofrequency (MNRF). With this procedure, each individual needle conducts a radiofrequency current, causing formation of small, hot zones of damage which are called radiofrequency thermal zones.

This heat causes collagen denaturation and leads to tissue shrinkage or contraction once the appropriate temperature is reached. The local injury induced by microneedles causes release of growth factors which aid collagen production.

MNRF offers minimal downtime compared to fully ablative treatments for acne scars. One key difference between MNRF and fractional lasers include mechanical disruption of the scar tissue strands.  

3. TCA CROSS (Trichloroacetic Acid Chemical Reconstruction Of Skin Scars):

100% TCA is applied to the base of ice-pick scars. It remains one of the most effective and economical treatments for ice-pick scarring.

The acid triggers inflammation in the skin. This is followed by healing and collagen synthesis which fills the defects in the skin, obliterating the scars and evening out the skin surface. Multiple treatments can be needed. Done under expert hands, this is an extremely safe procedure with extremely gratifying results.

Other options for acne scarring include dermal fillers, platelet rich plasma and chemical peels. Often, a combination of treatments is needed in order to achieve the best results.

No matter what treatment modality is chosen, fresh scars (which have developed within the last six months to one year) often respond better than older ones.  Results are often superior when treatment is initiated early. 

Initially, there had been a lot of debate about isotretinoin increasing the risk of hypertrophic scarring and keloid formation after scar revision and other dermatosurgical procedures. However, recent recommendations state that scar revision procedures are completely safe even in those patients currently on isotretinoin. Instead of completely avoiding such procedures in case you are on isotretinoin, it is ideal to do a test patch in order to establish safety of the procedure, prior to treating the entire affected area. 

Lastly, prevention is better than cure! It is important to get active acne treated early so that chances of scarring are reduced. Likewise, once scars develop, it is essential that they be treated early for best results.

References:

1. Kim, J., Lee, Y. I., Kim, J., Jung, J. Y., Lee, W. J., & Lee, J. H. (2020). Safety of Combined Fractional Microneedle Radiofrequency and CO2 as an Early Intervention for Inflammatory Acne and Scarring Treated With Concomitant Isotretinoin. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 46(10), e71–e77.

2. Abdel Hay R, Shalaby K, Zaher H, et al. Interventions for acne scars. Cochrane Database Syst Rev. 2016;4(4):CD011946. Published 2016 Apr 3. doi:10.1002/14651858.CD011946.pub2

3. Bhardwaj D, Khunger N. An Assessment of the Efficacy and Safety of CROSS Technique with 100% TCA in the Management of Ice Pick Acne Scars. J Cutan Aesthet Surg. 2010;3(2):93-96. doi:10.4103/0974-2077.69020

4. Mysore V, Omprakash HM, Khatri GN. Isotretinoin and dermatosurgical procedures. Indian J Dermatol Venereol Leprol. 2019;85(1):18-23. doi:10.4103/ijdvl.IJDVL_96_17