Acne scars are a notoriously difficult problem to treat. Many older therapies relied on deep removal of layers of skin, long healing times, and potential pigmentation (skin color) difficulites. In addition, many of the older therapies could not be used in darker pigmented patients. Luckily, over the last several years, some new and exciting acne scar therapies have come to fruition. Dr. Shah offers the latest in acne scar treatments.
Dr. Shah uses a symbiotic approach to acne scars. He has found that more than one mode of treatment provides the best results. This approach involves switching between techniques to avoid acne scar plateau.
Post-acne scarring is quite common. An atrophic acne scar is where permanent, postinflammation degradation of the dermal surface. About 95% of acne patients will have some degree of acne scarring. Acne scarring tends to look worse with aging.
There are said to be three different phases of acne scarring:
- Inflammation- this is where inflammatory mediators are brought about and swelling and localized inflammation is seen.
- Granulation Tissue Formation.
- Matrix remodeling- imbalance of metalloproteinases and mmp inhibitors.
The scars occur as there is degradation of collagen fibers and subcutaneous fat. There is also thought to be a genetic disposition of some patients to scar versus others.
ACNE SCAR TREATMENTS
CROSS (CHEMICAL RECONSTRUCTION OF SKIN SCARS)
CROSS is a new approach to acne scars. Using the strength of a deep peel, Dr. Shah selectively targets acne scars while sparing the remainder of the skin. He treats specific scars in a highly technical and specific manner. The stimulation of the deep peel encourages collagen formation, flattening acne scars and improving skin texture. The benefit of targeted selection is that the recovery period of chemical peel is limited to the treated areas. In addition, many drawbacks of deep chemical peels can be avoided including pigmentary abnormalities, erythema, and scarring. This technique can be used in all skin types including Caucasian, Asian, African American.
CROSS TCA works with specific types of acne scars. Icepick, pores, and some boxcars respond best to this approach. Recovery from this technique often involves the early formation of a white spot which is replaced by a scab. The scab falls off and then underlying redness can be seen in the area treated with the CROSS TCA. The redness typically dissipates in a week but can last longer in select patients. Patients typically repeat multiple treatments for optimal results.
MEDICAL ROLL CIT
The medical roll CIT (collagen induction therapy ) is a procedure developed to promote collagen deposition in the dermis, just below the surface of the skin. It is an effective procedure for acne scarring and upper lip wrinkles.
The developers of the medical roll CIT found that tattooed skin was smoother than non-tattooed skin. They found that the stimulation of the needles created focal areas of stimulation to the dermis, inducing the creation of collagen. In order to further stimulate collagen, topical vitamin A and C are applied before and after the roll CIT therapy. Vitamins A and C can more effectively penetrate the deeper layers of the dermis after medical roll CIT session.
While other modalities target collagen by removing lasers of skin, the Medical Roll CIT can stimulate collagen while leaving the majority of the superficial skin intact. The benefit to the patient is less pain in recovery, quicker recovery, and less chance of scarring or pigmentation changes than ablative skin therapies. In addition, the medical Roll CIT can be used all skin types safely.
The roll CIT is a highly stimulating procedure which requires a combination of a light sedative, anesthetic blocks and topical anesthesia. Most patients opt to have this procedure done in the office setting. Recovery involves swelling and in some cases bruising which typically resolves over a period of 4 to 5 days. Medical Roll CIT is effective in all acne scar types.
Dermabrasion is an older technique, yet still effective in select types of scars. Dermabrasion works by removing the superficial layers of skin with a diamond burr. When the skin heals, it will be smoother and scars may be less visible. Deep scars and ice pick scars are not good candidates for this type of therapy. Darker skin types are also not good candidates for this therapy. Most patients use dermabrasion as a “finishing” procedure once they have adequately stimulate collagen.
Lasers can be helpful in improving texture and lessening scars in some patients. They are an alternative to dermabrasion. Dr. Shah uses a combination of erbium, fractionated erbium, C02, and fractionated C02 to resurface the face. A laser is a relatively superficial resurfacing modality but can improve texture with multiple treatments.
Subcision is when deeper scars are released with a needle and relies on blood and body fluid to lift scars to surface of skin. Unfortunately, this technique can have drawback of unpredictable nature and temporary lifting of scars only to have them become depressed again. Dr. Shah utilizes a different approach where he subcises the skina nd then uses fine sutures to maintain the improved skin and scar position. He also subcises skin and maintains position with dermal fillers to allow for the newly positioned skin to heal in a flatter configuration.
TYPES OF ACNE SCARS
Just as there is more than one type of acne scar treatment, there is more than one type of acne scar.
Box Car Scar: The box car scars or boxcar scars can be treated with a variety of techniques including CrossTCA or Medical Roll-CIT
Icepick Scars: The icepick scars can be either deep or shallow pits. The scars can be treated by direct excision, Cross TCA.
Rolling Scars: Rolling scars usually are tissues which appear normal but have undulations within the skin. The can respond to Medical Roll-CIT or subcision with filler placement
Raised Scars: Raised scars can be a result of acne and occur on nose/chin and torso. Larger scars may respond to intralesional steroid injection.
Large Pore: Large Pores are very difficult to treat but some modalities which can benefit this include intradermal botulinim toxin and facial resurfacing.
Goodman and Barron Classification of Acne Scar Severity
- Grade 1 Maccular scarring or flat scarring that is charcterized by flat area of increase or decreased pigmentation visible from a distance of >500mm
- Grade 2 Mild disease that is visible at distances of >500 mm and can be covered up by make-up
- Grade 3 Moderate disease that is visible at > 500 mm and is not easily covered up by make-up or the normal shadow of a shaved beard. Stretching the skin can flatten the scar.
- Grade 4 Severe disease as in Grade 3 but is not flattened out by stretching the skin
The Science Behind Acne
Acne is a common skin inflammation. When hair follicles or pores in the skin get trapped, the acne bacteria (Propionibacterium acnes) multiply in the pit and become inflamed. There are many other factors in the acne story such as hormones. When hormonal changes at puberty create excess oil, pores become blocked and are an open invitation to Acne bacteria. Commonly, patients are placed on systemic agents such as birth control antibiotics or oral antibiotics. The problem with such treatments is that it effects the entire body, can be cumbersome and inconvenient to the patient. In addition, long term systemic antibiotics can lead to antibiotic resistance.
The Intense Pulsed Light System works by two mechanisms. First of all, by reducing oil gland function while reducing the amount of the Acne bacteria. When used in combination with an enzyme peel which helps exfoliate and open the pores, acne can be dramatically improved. Intense Pulsed Light treatments are revolutionizing the treatment of acne with easy, quick and effective treatments to suppress acne without the problems associated with systemic therapies. Finally, your acne treatment is not complete with a skin care home regimen customized to your skin, age, and problematic skin.
Acne scarring can be devastating for many reasons. For younger individuals, being taunted by their peers or lowered self-esteem is a reality. For adults, the scarring may also affect self-esteem and, unfortunately, have a subliminal influence on hiring and promotion decisions as well as dating and social acceptance.
Prior to the advent of laser skin resurfacing, the main option that existed was dermabrasion. CO2 laser resurfacing has all but replaced dermabrasion because it is a much more predictable and safer procedure.
The mechanism of action of laser resurfacing is to destroy all the outer layers of skin. When the skin heals, it produces new collagen and the new skin is smoother, tighter and with less pigment and scars. The new skin is red at first, then pink, then heals back to normal.
The laser procedure can lighten the color of the facial skin but this actually makes the patient look younger since the sun damage is gone. Extreme color changes are very rare. Although laser resurfacing can be very dramatic it is important for acne scar patients to realize that severe scarring will require multiple treatments. Many patients are satisfied with a single treatment while others have repeat touch up laser treatments. The touch up treatments are generally much simpler and can frequently be performed under local anesthesia. Some people require multiple touch up appointments with progressively less area treated until in some cases we are treating single scars.
What causes acne scars?
When the body has a vigorous response, almost inappropriately strong, to acne bacteria, this can lead to inflammation. Intense inflammation over time cause scarring. Some people are more prone to scarring than others. Some patients with intense inflammation can end up with significant disfiguring scars.
The types of acne scars
There are different kinds of acne scars: ice pick, atrophic, and hypertrophic. Ice pick scars are deep pitted scars with steep edges. Atrophic scars are pitted but have smooth borders and are not as deep. Hypertrophic scars, more common on the back and chest, are thick, lumpy scars that sit above the surface of the skin.
FREQUENTLY ASKED QUESTIONS
What is the downtime for the Medical Roll CIT skin procedure?
The downtime is typically about 4 days.
Am I able to wear makeup to hide the redness a week after the Medical Roll CIT procedure?
You are able to wear makeup after one week once you have healed.
What potential complications or side effects should I expect from the Medical Roll CIT procedure?
Overall the Medical Roll CIT procedure is very safe. However, realistic side effects that you may expect are prolonged swelling and redness.
What is the best treatment for acne scars?
The most safe and effective treatment for the majority of patients with acne scars is the Fractional CO2 Laser. This laser is a new, so called “fractional” laser. This means that the laser works by resurfacing only a “fraction” of the skin at a time, leaving the surrounding area intact for faster healing. This vastly reduces the incidence of side effects and has given us the ability to treat all skin types.
How does the Fractional CO2 laser work?
The CO2 fractional laser pokes tiny microscopic holes in the skin down past the epidermis and into the dermis. These holes cause new collagen to be generated which fills in the acne scars and creates rejuvenated smoother skin.
What kind of results can I expect from this laser treatment?
Most patients start to notice improvements in their skin as early as 1 week after the treatment. Continued improvements occur for the next 6 months and peak at around month 6. Most patients notice between 50-70% improvement of the condition treated. However, results vary by individual.
How many treatments will it take?
The vast majority of patients require only 1 treatment to achieve the desired results. Since the treated area continues to improve for the 6 months following the laser treatment, we re-evaluate the need for any additional treatments at that time. All treatments are performed in our practice located off Michigan Avenue in Chicago.
Is Fractional CO2 laser treatments safe to treat acne scars in darker skin types?
Dr. Shah safely treats acne scars in patients with all skin types including Asian, Indian, and African-American skin. An experienced laser surgeon is needed to treat darker skin types safely.
What is the downtime for this laser treatment?
The fractional CO2 laser causes a wound in the skin which means you will have three to four days of downtime when the skin is healing. During that time you have to apply an ointment frequently to your face keep the skin greasy, which makes healing faster.
What are the side effects of Fractional CO2 resurfacing?
The main risks are temporary or long-lasting light or dark spots from treatment. Very rarely scarring can still result. For these reasons it is important to be treated by an experienced laser surgeon.
What type of anesthesia is used during the procedure?
The whole procedure is done under local or topical anesthesia. You are awake and comfortable the entire time. Prior to the procedure, topical numbing cream is applied for 60-90 minutes. In addition, valium is given prior to the procedure to facilitate relaxation. Using these measures there is usually minimal discomfort during the resurfacing procedure.