53. Blemishes vs. Scars

Doctor Jacob here today, and we're talking about blemishes vs. scars. This one is real easy.

Blemishes are color changes on the skin - sometimes pink, red or darker brown. Blemishes cannot be felt, so if you close your eye and run your finger across a blemish, you won't be able to tell it's there, it's only able to be seen, whereas scars result in textural changes in the actual skin surface. Scars can be raised, called hypertrophic scars, or depressed, called atrophic scars.

Scars are broken down further into other subtypes, however, for blemishes it's very easy. If you cannot feel them with your fingertip, they're blemishes and not scars and that's good news, because blemishes often - not always, but often - fade by themselves with enough time, for example six months, but there are certain things that we can do to speed the resolution of blemishes, and that depends on what type. There is the pink or red ones, and then there is the brown ones.

So let's first talk about pink or red blemishes. Medically, this is called post-inflammatory erythema. Erythema means redness, which signifies an increase in blood flow into the skin.

These are kind of common after inflammatory acne, especially on the cheeks. Blemishes of this type can be present in the hormonal distribution in women with adult onset female hormonal acne, and treatment of these red or pink blemishes usually just takes time and can be hastened with a little bit of both a retinoid, such as tretinoin or Retin-A, or adapalene, as well as a little bit of azelaic acid, or one of its modified chemical derivatives: Azelex's 20% azelaic acid creme, which is prescription, and there is also a link to a blemish buster which is an over-the-counter derivative you can buy online - it's on the website, for blemish treatments. That one's a chemical derivative of azelaic acid which doesn't require a prescription; it works pretty well for these red blemishes.

Now let's talk about laser. There are certain redness lasers, for example pulsed dye laser or Vbeam, which can help the resolution of these, but for many patients it's an expensive treatment and with just some topicals and enough time the blemishes go away.

That being said, let's talk about brown blemishes, usually seen in darker skin types. These blemishes are given the name of post-inflammatory hyperpigmentation. Hyperpigmentation is of course an increase in the skin pigment. These kind of fall into two categories: ones that fade with time, and ones that do not. That depends on where the pigment is in the skin, for the most part.

If the pigment is in the top layer, the epidermis, it tends to fade with time and sun protection, along with a combination of a retinoid like tretinoin or adapalene, and sometimes can be hastened with a fading cream, which is hydroquinone cream. Sun protection is essential for these dark blemishes to fade away. I usually start with a retinoid topically, plus sun protection. If that's been going on and there's no improvement, if you've been doing a retinoid and sun protection and you're not getting any better, that probably means the pigment is deeper in the skin, in the dermis, in which case we have to get into some fancy things to get this pigment to fade away. Usually I give it three or four months at least, even up to six months before I start getting into these things. What I'm talking about is a gentle, fractionated carbon dioxide laser resurfacing of the skin. That sounds like a mouthful. Basically what it is is every two weeks - it's a very special type of laser peel, where very low energies are used to take laser light and poke holes into the skin to stimulate remodeling and reabsorption of the pigment. It has to be done by an experienced healthcare professional, and I usually do every two to three weeks for anywhere from five to eight sessions. That typically helps fade a lot of these post-inflammatory hyperpigmentations in which the pigment is deeper in the dermis.

Usually this type of hyperpigmentation is seen in patients of darker skin types, for example African-American skin types, East-Indian darker skin types, and in certain darker Asian or Latino skin types.

To summarize, there is post-inflammatory erythema, which fades with time. It can be helped with a retinoid topically, as well as azelaic acid or its derivative. Certain lasers can help, but they're often unnecessary, as waiting time gets these things to fade. Next up, there's post-inflammatory hyperpigmentations, which are brown marks after acne, usually more common in darker skin types. These are first treated with a combination of time plus a retinoid, and if that doesn't do it even after several months of trying, we think about multiple sessions every few weeks of very gentle, fractionated laser resurfacing.

I'm Doctor Jacob, we'll see you next time.