Acne scars occur as a result of a full thickness injury to the skin from inflammatory acne, most notably nodulocystic acne. The injury involves the dermis layer of the skin, resulting in irregularities on the surface of the skin. Acne scars are different from post-inflammatory pigmentation, acne marks or blemishes which are temporary and usually resolve with time on their own.
Scars are, by definition, permanent and irreversible. However, there are methods to make them less obvious. When treating acne scars, the first step is to ensure good acne control as some treatments may trigger breakouts. Next, it is important to identify the type of scars present, as this will determine which treatments are the most suitable.
Common scar types include rolling scars, boxcar scars and ice pick scars.
Types of Scars
These are scars that are wide and have steep, perpendicular walls. They may be triangular, square or rectangular, in the shape of a matchbox.
They are best treated with subcision, followed by CO2 laser or radiofrequency microneedle. If small, they can also be treated effectively with TCA CROSS.
Ice Pick Scars
These scars are narrow and deep, with steep edges, giving the appearance of being created by an ice pick.
As the base of these scars tend to go very deep, lasers are not very effective in treating them. TCA CROSS, where small amounts of TCA are applied to the base of the scars with an applicator, is one of the few ways that are effective in treating these scars. Alternatively, they can also be excised by a plastic surgeon or dermatologist trained in surgical procedures.
These scars typically have edges with a gentle gradient. They have the appearance of mountains and valleys.
They may get more obvious with age
Rolling scars are best treated with a series of subcision, followed by CO2 laser or radiofrequency microneedle.
We have a wide range of treatment options at Astute to ensure that we can tackle a variety of scars. Treating acne scars is a long process. We recommend that treatments be spaced out to at least 6 weeks in between as the scars take time to heal and improve from treatments.
To get the best results, it is better to treat deeper scars with methods like subcision and TCA CROSS first, before commencing laser treatments.
Acne scars are often more than skin deep. Beneath the skin, we often find fibrous scar tissue pulling down onto the skin. As these are situated very deep, devices like lasers will not be able to reach them.
Subcision is a procedure where an instrument is placed under the skin to manually break up scar tissue that is holding the skin down. The repeated movement under the skin also stimulates collagen production. Traditionally, it is done with a hypodermic needle. We now also have the choice of using a blunt tipped instrument known as a cannula to lessen the downtime and speed up recovery.
We often put small amounts of filler beneath the scars that we subcise to prevent the scars from reattaching. Certain fillers like Radiesse also stimulate collagen production, allowing better resolution of the scars.
Downtime from subcision comes in the form of bruising and swelling. If done with a cannula, the bruising and swelling tend to be milder and recover in about 1 week.
We recommend subcision as a first step for most scar types.
Fractional CO2 Laser
The CO2 laser is probably the most well-known treatment for acne scars. Traditionally, the entire surface area is treated, resulting in a very long downtime and high risks of complications. These days, we make use of its fractionated mode, where only a fraction of the skin’s surface area is treated. This allows for safer treatments and faster recovery.
Immediately after treatment, patients may experience some swelling and redness over the treated areas. There will be many tiny white dots on the treated areas. These white dots are areas that have just been lasered. They will turn into brown scabs over time. These fall off and fully resolve in about 5 to 7 days on average. We recommend using the Calecim serum post treatment to hasten recovery and optimise results.
It is mandatory to not get too much sun before and after CO2 laser treatments to minimize the risk of skin colour changes.
We use the DEKA Smartxide CO2 Laser, which is one of the leading brands of CO2 lasers in the market. Using a reliable CO2 laser machine is important, as it allows us to individualise treatment parameters for each patient, delivering more effective and safer treatments.
The CO2 laser is excellent for treating shallower scars. We recommend using the CO2 laser during the later stages of treatment when the deeper scars have been made shallower with other treatments.
Certain scar types can be very deep, and lasers cannot reach the bottom of these scars. When performing TCA CROSS (Trichloroacetic Acid Chemical Reconstruction of Skin Scars), we place a drop of concentrated TCA with an applicator to the bottom of the scar to damage it. This will prompt the skin to repair the damaged area, improving the scar appearance in the process.
There will be some swelling and redness around the treated areas, and the scars may scab in the process. It is very important during this period to not get too much sun exposure or the treated areas may temporarily darken or remain red for a prolonged period. It takes about 1 to 2 weeks for the scabs to fall off.
TCA CROSS is one of few ways of treating ice pick scars. It is also suitable for smaller boxcar scars.
Radiofrequency microneedles are a class of devices that transmits radiofrequency (RF) energy into the skin via a cluster of tiny needles. These needles allow us to bypass the epidermis, the outer layer of skin, to deliver the energy to the dermis of the skin where most of the scarring is. Heating that layer up causes some damage, prompting the skin to regenerate and repair the scarred areas. Because the outer layer of the skin is spared, the downtime is shorter than that of the Fractional CO2 laser. Patients can expect some redness and mild swelling for about 3 days after treatment.
We use the Endymed Intsensif, which allows for highly customisable parameters, allowing us to individualise treatments to our patients’ needs.
We recommend this treatment for those who cannot have a downtime that is too long.
The Astute Programme
In general, we would like to start our patients on a daily application of a retinoid cream. Retinoids, when applied over the course of several months, has been shown to slightly the appearance of acne scars by stimulating collagen production. Furthermore, pretreating with retinoids before acne scar treatments may improve the results of these treatments and also lessen the possibility of complications.
Following that, what treatment you will have planned for you depends on the type of scars that you have, your lifestyle, medical history and personal preferences. Every one of us is unique and the approach to acne scars should be no different. We do not use a one-size-fits-all approach. Every patient will have a different combination of scars. A bespoke approach will yield us the best results.
For example, usually for rolling scars and boxcar scars, 1-3 sessions of subcision with Radiesse will be done as a first step. Depending on response, we would then recommend a series of about 6-12 sessions of CO2 lasers or RF Micro-needling (Endymed intensif) to be done after subcision.
Ice pick scars require a series of about sessions 6-8 TCA CROSS. When the scars are shallower, a series of about 6-12 sessions Fractional CO2 lasers will be recommended to smoothen out the skin texture.
We like to end each treatment session with the application of Calecim Serum. Calecim contains proteins derived from umbilical cord lining. It has been shown in studies that these proteins help with the repair of skin, shortening downtime. It also has anti-aging effects & preventing the chances of PIH risk.
Calecim can also be applied through Dermoelectroporation (DEP). DEP utilises gentle electric current to open up microchannels in the skin so that anything applied to the skin can be absorbed more easily, without the need for injections. This is a comfortable, painless process. This is an important additional step for better and faster healing. It can be done 2 weeks after fractional CO2 laser or RF microneedling.
This is just a general guide, and the treatment plan will likely vary among patients, depending on response of the scars to treatments.
Our acne scar programme consists of 6 treatment sessions. We do not dictate what these treatments will be. An initial consult will consist of a frank discussion with our doctors on what treatments are the most appropriate for your scar type, lifestyle and preferences. Only then will your personalised treatment plan be decided.