Acne is a common skin disease that generally results in scarring. Acne Scars secondary to acne can lead to physical disfigurement, and the psychosocial impact can be profound. Early and adequate treatment of acne is the best means to minimize and prevent acne scarring. Acne scars look worse than acne, Consult Dr. Vijay Kumar and find an apt Acne Scar Treatment in Delhi.
Although various therapies may reduce the prominence of acne scars, no cure obliterates acne scars. A multimodality approach to Acne scar treatment is usually necessary to achieve the best cosmetic results. The selection of a therapy method is based upon factors such as the type and degree of acne scarring, patient preference, side effects, cost, and treatment availability.
PATHOGENESIS of Acne scar
Acne scarring represents an altered wound healing response to cutaneous inflammation, leading to an imbalance in matrix degradation and collagen biosynthesis. Although scarring is a common consequence of inflammatory acne vulgaris, not all patients develop scarring. The reasons for discrepancies in the propensity to scar are not clear.
One theory focuses on the nature of the inflammatory response in determining which patients develop scarring. This theory is supported by an immunohistochemical study of 8 patients not prone to acne scarring and 11 patients prone to acne scarring. Individuals from early lesions from patients who were not inclined to acne scarring demonstrated a large, active, nonspecific immune response that subsided with lesion resolution. In contrast, patients prone to acne scarring had a smaller, more specific immune response in early lesions increased and activated in resolving lesions. This persistent inflammation in healing tissue may contribute to scarring.
CLASSIFICATION of Acne scars
— Acne scars can be divided based upon morphology into atrophic scars and hypertrophic scars. Maybe, patients have more than one type of scar.
Atrophic scars- Atrophic scars, the most common type of acne scars, are caused by the destruction and loss of collagen in the dermis and present as indentations in the skin. Destructive inflammation in the deep dermis and subsequent contraction is thought to result in the indented appearance.
Atrophic scars may be subclassified into ice pick, rolling, and boxcar scars.
- Ice pick scars: Ice pick scars are usually narrow (<2 mm), deep, sharply defined tracts that can reach deep dermis or subcutaneous tissue. Ice pick scars are typically wider at the epithelial surface and taper as they go more in-depth.
- Rolling scars: Rolling scars are usually wider (4 to 5 mm) and more shallow than ice pick scars and produce an undulating appearance in otherwise normal-appearing skin. The skin surface’s rise and fall result from the dermis’ abnormal fibrous attachment to the subcutis.
- Boxcar scars: Boxcar scars are wider at the base than ice pick scars and do not taper. These round- to oval-shaped skin dimples have sharp margins and can be either shallow (<0.5 mm) or deep (>0.5 mm.
Hypertrophic scars and keloids: Hypertrophic acne scars and keloids are less common than atrophic acne scars and are characterized by collagen gain after resolving an acne lesion, resulting in a firm, raised papule or plaque. Hypertrophic scars do not spread beyond the margin of the original wound. In contrast, keloids extend beyond the margin of the original wound.
Treatments for Acne Scars
Overall, high-quality trials of interventions for acne scars are lacking. A well-organized review of randomized trials found insufficient evidence to recommend any particular intervention as a first-line treatment. More high-quality placebo-controlled trials are needed to clarify the efficacy of treatments. The treatment approach reviewed here is based upon a review of the available evidence and consideration of the practical aspects of treatment.
Chemical peels For Acne scars
Chemical peels can be effective treatments for acne scars. As with laser resurfacing, injury to the skin caused by chemical peels can stimulate a wound healing response with collagen remodeling.
Chemical peels are classified into superficial, medium-depth, and deep chemical peels according to skin injury depth.
- Superficial chemical peels, such as salicylic acid, lactic acid, glycolic acid, Jessner solution, and 10% to 25% trichloroacetic acid affect only the epidermis.
- Medium depth chemical peels, such as combination treatment with Jessner solution and 35% to 50% trichloroacetic acid, injure the skin to the papillary dermis level.
- A deep chemical peel with phenol damages the skin to the story of the mid-reticular dermis.
Although acne scars were previously one of the most common indications for dermabrasion, the use of dermabrasion for acne scars has fallen significantly since the rise in the use of laser resurfacing therapy. However, in skilled hands, dermabrasion can be highly effective for severe acne scarring.
Dermabrasion involves using tools (e.g., high-speed brush, diamond cylinder, frail, or silicon carbide sandpaper) to remove the epidermis or epidermis and part of the dermis. An advantage of the procedure is that it allows the clinician to etch scar edges precisely without thermal injury. However, dermabrasion is highly operator-dependent, requires meticulous intraoperative assistance, and has the potential for severe postoperative scarring, pigmentation, and milia formation.
Microdermabrasion is a more simple procedure in which abrasive crystals (e.g., aluminum oxide crystals) are propelled onto the skin within a controlled vacuum suction system. The depth of abrasion during microdermabrasion remains in the epidermis. Thus, improvement in acne scars after microdermabrasion is minimal.
Skin needling procedures can improve acne scars. Like fractional lasers, needling procedures induce small columns of damage in the epidermis and dermis, leaving intervening skin untouched. A needling device typically consists of a circumferentially studded cylinder with 1 to 2.5 mm long needles. The device is rolled over the skin’s surface to form numerous perforations in the epidermis and dermis to stimulate neo collagenases. Advantages of skin needling include low cost, a relatively short recovery period (two to three days), and a shallow risk for post inflammatory hyperpigmentation.
Ablative fractional laser resurfacing for Acne scars
Although fractional ablative lasers (Er: YAG, yttrium scandium-gallium-garnet [Er: YSSG], and CO2 lasers) can improve acne scars, we favor nonablative fractional laser resurfacing when it is available because available evidence suggests that ablative fractional laser treatment is associated with more significant side effects and little extra benefit in response to treatment.
Ablative fractional lasers may be useful for treating focal areas of hypertrophic and tethered scarring.
Traditional ablative laser resurfacing
Traditional ablative laser resurfacing involves using a 2940 nm erbium: yttrium aluminum garnet (Er: YAG) laser or 10,600 nm carbon dioxide (CO2 ) laser. These lasers target water in the skin, resulting in the epidermis and dermis ablation in exact increments. The thermal injury caused by the laser promotes collagen contraction, collagen remodeling, and skin tightening, effects that can result in improvement in the appearance of scars.
Generalized atrophic facial for Acne scars
Frequently, patients present to treat facial acne scars have multiple scars. This presentation is best managed with a field approach to treatment. Patients who require only a few specific scars can be managed with some of the same treatments.
Because no single treatment completely removes acne scars, a multimodality approach to generalized facial acne scars is most likely to provide the best treatment results. Our ideal result-focused approach to generalized atrophic facial acne scars can be summarized in three key steps:
- Step 1: An initial treatment phase consists of erythema treatment within scars (if present) and focal treatments to target individual scars that are likely to be resistant to collagen remodeling procedures.
- Step 2: A collagen remodeling procedure (the gold standard is full-face resurfacing with a traditional ablative laser)
Step 3: Additional treatments designed to address resistant scars and augment the results of the collagen remodeling procedure (e.g., injectable soft tissue fillers, additional nonablative or ablative fractional laser treatments)
Pulsed-dye laser therapy improves erythema in scars by targeting oxyhemoglobin within vascular structures in the skin.
Successful treatment of acne scar erythema with a pulsed-dye laser usually requires three to four or more treatments given at approximately one-month intervals.
Focal treatment of scar
Deep ice pick scars, and deep boxcar scars may respond poorly to laser resurfacing and other collagen remodeling procedures. Treatment of prominent scars of these types with one of the modalities below may improve the final results of treatment.
CROSS technique (Chemical reconstruction of skin scars technique)
- Indication: Ice pick and narrow boxcar scars.
- Description: A high-strength trichloroacetic acid (TCA) peel solution (100%) is placed directly in the base of scars to ablate the epithelial wall and to promote dermal remodeling.
Other therapies for Acne scars
In our experience, other light-based devices used to treat vascular lesions, such as the potassium titanyl phosphate (KTP) laser and intense pulsed-light devices, can be effective for scar erythema. In addition, marked clinical improvement in post inflammatory erythema in acne scars has been reported after non ablative fractional laser treatment.