54. Treating Acne Scars

Doctor Jacob here, and today we're talking about treating acne scars.

There's one major principle when treating acne scars, and that's first treat the acne. A lot of patients with scarring acne come to me asking me to treat their scars, and I end up putting the patients on a course of Accutane first. Once we treat their acne, the skin has to heal and recover from the Accutane, and then in three or four months afterwards we are ready to being treating the acne scars. But until the acne is controlled, it doesn't make sense to go after the scarring.

First principle of treating acne scars is treat the acne. If that takes Accutane, the skin needs at least three or four months to heal before getting into acne scar treatments.

Treatment of acne scars should be done by an expert who is very familiar with all the different treatments for acne scarring. I do a lot of treatment for acne scarring, and one of the tools I use very frequently is the carbon dioxide laser. There are many different brands of carbon dioxide laser out there, and it's kind of like Coke and Pepsi - they all work, but you do have to know what you're doing with the particular laser machine. Brands include Fraxel, UltraPulse, Deka and others.

There is some significant downtime after fractional carbon dioxide skin resurfacing. The patient will have to put on sunscreen and basically wear a hat every time going out, be putting on cream every couple hours for the first couple days, and in my experience any treatment that's less than five days worth of the downtime in peeling from this type of a laser peel really doesn't get a good enough benefit to justify the treatment. So first off you have to have the down time.

Second, these treatments can get expensive - they're generally not covered by insurances - and third, it takes multiple sessions. So for most patients with mild acne scarring one or two sessions may be enough, but for more severe acne scarring it can take five or six sessions to get a good improvement. When I say a good improvement, we're talking a 60% or 70% improvement in the appearance as judged by the eye of the acne scars, with the fractional CO2 laser.

This type of laser resurfacing can help build collagen under the scars and can help correct the textural unevenness that results. Often times at the same day that I do fractional laser resurfacing for patients, I do a procedure called TCA Cross. TCA Cross stands for trichloroacetic acid chemical reconstruction of skin scars. It involves taking basically a toothpick, tipping it into a strong solution of TCA (trichloroacetic acid) and then touching the toothpick into the acne scars. This helps the scar basically reepithelialize by getting rid of the old skin surface. What does that mean? The skin is able to heal a new skin surface, but first we have to wipe away the old skin surface, and doing this on the same day as the fractional laser promotes the healing and evenness of skin pigmentation that results.

Basically, the TCA Cross technique can leave approximately 10 days of downtime where there will be little scabs. At first it turns the area white, and then the area is allowed to heal and it scabs up. It's only applied to a small area of the scar, for example a three-millimeter area of the scar, nothing bigger than that; sometimes even to one or two-millimeter area scars.

There are other types of lasers such as fractional non-ablative lasers. Unfortunately, although these do stimulate collagen remodeling, often times numerous sessions are needed, and the level of improvement generally is not up to what you get with fractional ablative resurfacing. Ablative means injuring more, whereas non-ablative means just delivering heat.

The fractional carbon dioxide laser, which is typically thought of as the gold standard for fractional ablative technology is what I use the most of, combined in many cases with TCA Cross.

Sometimes before embarking on this type of laser treatment there are some scars that you can tell from experience just are not going to be able to be treated, so often times what we do is we excise those scars. We actually numb the area with a local injection of anesthetic and remove the scar surgically, and stitch the skin together with very fine stitches, then after about six weeks of healing time we go about treating with a laser resurfacing, so that we can kind of even out the surgical scar that we created. That can help a lot for some bigger or very deep scars.

There is another technique called subcision, which I often embark on before treating scars with laser. Subcision involves inserting a fairly stiff needle, going under the skin and sweeping back and forth with a needle in order to free the superficial skin layers from the deeper skin structures. This is most useful for bound down type scars, where if the skin is moved gently with a finger and the scar basically doesn't move with the rest of the skin, subcision can help disrupt these adhesions or bonds between the top layer of the skin and deeper tissues.

There are certain types of fillers which can be placed into the skin right underneath the acne scar to lift the scar up, and usually subcision is done prior to fillers in many cases, depending on the severity of the scarring.

All in all, a combination of excision, subcision, fillers, sometimes a technique called punch grafting in which skin is imported from a distant location to fill the hole taken by a scar, as well as fractional CO2 laser resurfacing, or in more mild cases fractional non-ablative resurfacing combined with TCA Cross. All these techniques are used in combination to give improvements to acne scars. In many cases, we can hope for a 60% to 70% maximal improvement, even with repeated treatments and bringing in all the treatment types I mentioned, everything under the sun.

Treatment of acne scars really never gets to perfection, so it's important that patients understand what we're able to do. Often times treatment is costly, because insurance in many cases does not cover the treatment of scarring. But don't give up hope, because we are certainly able to make significant improvements in even the toughest cases of acne scarring.

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