6 Things Your Doctor Is Not Telling You About the Treatment of Acne Scars
Persistent ghosts of past breakouts.
Acne scars are a reminder that the battle against acne is only half won even after sending our active acne into remission. These “battle scars” not only puncture holes into our self-esteem but are a major cause of stress as well. It is naïve to believe that acne is solely a teenage occurrence. In fact, there are many individuals who still continue to be plagued by it – in varying degrees of severity – well into their adulthood.
How do acne scars develop? What are the different types of scars?
In order to better understand the treatment of acne scars, it is essential to first know how acne scars develop. Rather counter-intuitively, our body’s natural wound healing process is in fact the culprit behind our acne scars. Acne is an inflammatory process, which will damage the different layers of our skin. This triggers a cascade of tissue repair processes, which eventually lead to these unsightly scars.
Generally, we can classify acne scars into atrophic or hypertrophic in nature; atrophic scars being more common than hypertrophic ones. There are 3 further sub-categories of atrophic scars, namely, icepick, boxcar and rolling.
There are certainly some acne scars which may present with other features such as redness and they are treated in a slightly different manner.
There is a wide selection of acne scars treatment in the market today. However, not all are equally suited or effective for each individual.
As such, this article endeavours to provide more insight into how these persistent ghosts of past breakouts came to be and more importantly, 6 things that your doctor is not telling you about the treatment of acne scars.
1. Ablative lasers
Laser therapy is generally recommended for patients with boxcar or rolling acne scars. Ablative lasers such as the CO2 laser and erbium YAG laser work by abrading the surface of the skin and hence smoothening out the appearance of the depressed acne scar. In addition, the lasers also increase the production of collagen in the skin. Although ablative lasers are highly effective, its potentially high risks of complications are sometimes not emphasised enough.
Some side effects include:
• Bacterial, fungal or viral infections,
• Persistent redness of the skin and even
• Increased pigmentation and scarring
In particular, over-treatment tends to be one of the main perpetrators behind the long-term complications.
Hence, it is pertinent to be aware of the pitfalls of these ablative lasers and use them with caution. This is especially so for the treatment of more sensitive areas of the skin such as the neck and chest.
2. Non-ablative lasers
Non-ablative lasers such as the Q switch, V Beam, Pico MLA and Diode lasers are the safer counterpart of ablative lasers. Unlike ablative lasers, non-ablative lasers do not abrade the surface of the skin. Rather, they work by stimulating the formation of collagen and in so doing, tightening the skin so as to raise the scar to the surface and reduce its depressed appearance.
However, while non-ablative lasers have a better side effect profile in comparison to ablative lasers, it tends not to achieve less impressive end results, which is something to consider as well.
Subcision works on the principle that atrophic scars are attached to underlying hypodermis via fibrous bands of scar tissue. By severing the fibrous tissue, the skin surface is “released” and will thus have a less depressed appearance. In addition, this process also allows the stimulation of collagen to take place, thus further smoothening out the appearance of the scar.
This procedure utilises a specialised needle to severe the fibrous scar tissue tethering the skin surface to the dermis and hypodermis. As such, it is the most effective in treating depressed scars like atrophic acne scars, stretchable scars from injury or surgery and chickenpox scars.
However, Subcision has several associated contraindications, which make some individuals unsuitable for this treatment. These may include:
• Personal history of being prone to hypertrophic and keloid scarring
• Ongoing active skin infections
• Medical history of bleeding disorders, or individuals on blood thinning medication
Micro-needling treatments, like Infini Acne Scar Treatment and Secret RF, are another alternative for acne scars. Micro-needling works in a similar way to Subcision in severing the fibrous tissue tethering the atrophic scars to the hypodermis. However, the 2 treatment methods work via different mechanisms: Subcision severs the tissue using mechanical methods (i.e. physically cutting the tissue), whereas Micro-needling does so with heat delivered via Radiofrequency (RF) energy.
During Micro-needling treatment, RF energy is delivered into the dermis via an array of micro-needles. These needles bypass the epidermis and delivers RF energy straight to the target area in the dermis. The RF energy from the needles heats up the surrounding tissue, severing the fibrous tethers, allowing the scar surface to rise and even out with the surrounding skin. Each treatment session also generates up to 50 000 micro-coagulation zones in the dermis, stimulating collagen production which help raise deep acne scars.
Micro-needling is much less invasive than Subcision as the micro-needles used are much thinner, and there is less physical movement within the dermis during the procedure.
Both Infini and Secret RF machines are able to adjust their treatment depths from 0.5mm to 3.5mm, allowing treatment of acne scars regardless of the depth.
Although Infini and Secret RF are both Micro-needling treatments utilising RF energy, there are important differences between the 2. Firstly, Infini uses insulated micro-needles while Secret use non-insulated ones. The insulation allows Infini to deliver RF energy precisely to the target depth with minimal loss of energy, allowing for more effective treatments. On the other hand, Secret RF is milder on the skin an generally has a shorter downtime of just up to 1 day (Infini may have downtime of up to 5 days). Lastly, the 2 also use RF of different frequencies, and tend to work better on different types of acne scars.
From experience, a combination of both Infini and Secret RF usually achieves the best results as the advantages of both are combined. The 2 treatments have synergistic effects together, and allows for significantly better coverage.
5. Dermal Fillers
As the name suggests, dermal fillers work by literally “filling” out the irregular bumps in the skin. Because of this, dermal fillers have limited effects on hypertrophic scars. On the other hand, they can do wonders to atrophic scars if used correctly.
There are many types and brands of dermal fillers on the market. However for acne scars, Ellanse is the filler of choice. While most other fillers on the market use hyaluronic acid (HA) as their main component, Ellanse utilises Poly-Caprolactone (PCL) microspheres as its principal component, suspended in a carboxymethylcellulose (CMC) gel carrier. Both components are highly bio-resorbable, and are broken down gradually after injection into the skin.
Ellanse acts on the skin via 2 different mechanisms. Firstly, the Ellanse gel directly adds volume to the skin like most other fillers, evening out the bumpy surfaces caused by atrophic scars. PCL microspheres in Ellanse will maintain their volume while dissolving until the molecules are almost completely dissolved, providing lasting effects. Secondly, the PCL microspheres directly stimulate collagen production in the dermis, repairing support structures. This double action allows Ellanse to deliver immediate, effective results which are maintained over the long-term.
Ellanse comes in 4 different packages: Ellanse-S, M, L and E. These differ in their longevity in the body, with S lasting for about a year, and E lasting for about 4 years.
6. Chemical peels
Chemical peels make use of mild acids such as glycolic or salicylic acid to gently exfoliate away the topmost layers of the epidermis, triggering natural healing processes and in turn help to rejuvenate the skin. Chemical peels are not only effective in treating acne scars, it can reverse some signs of aging as well.
While this is one of the more wallet-friendly options available for the treatment of acne scars, it does have some limitations. Firstly, Chemical peels are not recommended for patients with darker skin as they have and increased risk of hyperpigmentation while using undergoing this treatment.
Additionally, Chemical peels are the most effective at treating macular acne scars, but have limited effects on atrophic and hypertrophic scars. The treatment of these two types of scars would require topical retinoids and alpha-hydroxy acids to be added into one’s skincare routine on top of multiple sessions of chemical peels. Even then, the degree of improvement is highly variable and some patients may still not attain their desired look.
Results from acne scar removal treatments:
The aforementioned are but 6 common treatments that individuals may receive for their acne scars. As delineated in this article, there are certain contraindications that one should note before deciding whether or not to undergo a particular procedure.
It is thus of utmost importance to gather sufficient information about each treatment, its advantages and disadvantages. This will help you make an informed decision on what is the best for yourself.