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Clinical Insights: Achieving Superior Outcomes in Acne Scar Treatment

Updated: Jul 1

Dr. Farah treating a patient with acne scars using the Fotona SP Dynamis laser at AOKLINIK Penang.
Dr. Farah treating a patient's acne scars with the Fotona SP Dynamis laser at AOKLINIK Penang.

Acne vulgaris is a widespread issue, affecting people of various age groups. While the prevalence of acne scarring varies, many of my patients experience some degree of scarring. Here, I will address the most common type of acne scar— the atrophic scar— and discuss comprehensive treatment options.

Achieving optimal results in treating acne scars involves a tailored combination approach using multiple modalities. Managing acne scars should follow an algorithmic approach that targets each component of scarring. The first step is to address erythema, if present, as it is crucial for successful atrophic scar management. Erythema must be managed before focusing on atrophic scarring because it can hinder tissue reconstruction.

AOKLINIK Georgetown and Sungai Petani has received patients from diverse demographics, including neighbouring countries like Singapore and Indonesia, who share similar Fitzpatrick skin types with our fellow Malaysians. Most of these patients have undergone a daunting journey of unresolved acne and acne scar treatments and their complications. It is important to highlight that the treatment approach for atrophic scars is not one-size-fits-all. It will highly depend on the types of scars and whether generalized or individual scars predominate. Tailoring combination treatments to each patient offers the best chance of significant improvement. Early treatment of active acne is the best way to prevent or limit acne-related scarring.  It is crucial to treat active acne before addressing scar treatment to prevent a cycle where new lesions continue to scar areas that have already been treated.

In my clinical practice, I have encountered atrophic scars in nearly 80 to 90 percent of patients with acne and they are typically numerous. Treatment of generalized atrophic acne scars involves a field approach, including:

From my experience handling large samples of patients with concurrent acne and acne scars, I was able to achieve acne control and superficial resurfacing of shallow scars using chemical peels with minimal complications. These peels treat small, depressed scars but not icepick or deep boxcar scars. They induce skin injury, stimulating collagen remodelling and are categorized as superficial, medium, and deep based on the injury's depth. Superficial peels, such as lactic acid, salicylic acid, glycolic acid, Jessner solution, retinol peel, and 10 to 25% trichloroacetic acid, are useful for acne control and skin remodelling. These peels are selected according to each patient's skin type, acne, and scar severity.

The chemical reconstruction of skin scars (CROSS) technique combined with superficial peels is usually my selection for patients with existing sebum dysregulation and atrophic scars. The CROSS technique is indicated for icepick and narrow boxcar scars. It involves applying a high-strength trichloroacetic acid (TCA) peel (65–100%) to the scar's base to ablate the epithelial wall and promote dermal remodelling.

Most of my patients require field treatment for broad areas of scarring, with lasers and other resurfacing agents being the mainstay of treatment. The most important step is to prepare patients for resurfacing treatment by ensuring they have a healthy skin barrier, optimal nutrition, and good sun protection habits, as these factors play pivotal roles in minimizing the risks associated with laser therapy, especially in patients with higher Fitzpatrick skin photo-types.

Ablative lasers are regarded as the gold standard for treating acne scars, as they significantly improve scar appearance by promoting collagen contraction, remodelling, and skin tightening. However, these benefits come with drawbacks, such as significant procedural discomfort, an increased risk of dyspigmentation, infections and prolonged healing time compared to non-ablative lasers. I have encountered patients with prolonged healing post-ablative laser, which, upon further investigation, turns out to be due to iron deficiency. It has been a challenge for us medical practitioners to educate patients on the importance of nutritional balance and its impact on skin health. At AOKLINIK, we take a holistic approach and provide pre-emptive measures against the complications of laser therapy. This includes health and lifestyle screening for early detection of nutritional deficiencies and unhealthy habits such as poor sleep hygiene and smoking.

Another method that I am privileged to utilize is the combination of ablative and non-ablative laser modalities in treating patients with acne scars. Our cutting-edge Fotona SP Dynamis laser machine provides this dual laser wavelength, enabling better recovery and skin remodelling. In a pilot study conducted in our clinic, we compared the Er:YAG ablative laser to a combination of a 1,064nm laser with the Er:YAG ablative laser in patients with Fitzpatrick skin phototype IV. The study found that the combination offered slightly greater clinical improvement than the ablative laser alone, particularly in the treatment of deep scars.

At AOKLINIK, we frequently combine laser treatment with autologous PRP therapy to enhance wound healing, accelerate tissue repair, and reduce pain. PRP works synergistically with skin needling for atrophic acne scars, as needling creates pathways for PRP absorption, allowing additional platelets to aid in the healing process. When applied as both an intradermal injection and a topical application after ablative laser therapy, PRP significantly enhances the recovery of laser-damaged skin and improves the clinical appearance of acne scars.

A new and promising technique for managing acne scars involves the injection of semi-permanent fillers, which also have collagen stimulating properties. Hyaluronic acid fillers (HAF) work by enhancing soft tissue and improving the quality of the overlying skin. This approach is particularly beneficial for patients who cannot tolerate resurfacing treatments. In my practice, I have used this technique both as a monotherapy and in combination with subcision for patients with rolling and boxcar scars. Both types have shown improvement after a single treatment session.

To effectively treat rolling scars, which require correction of the subdermal component, subcision is often used in our clinic setting. This procedure involves inserting a needle under the acne scar to sever the fibrous components anchoring the scar below the dermis. By successfully releasing the fibrous tether, the scar is elevated, and new collagen formation is promoted through the body's natural healing process. Microneedling is another effective method for targeting collagen remodelling. This technique smooths facial skin and improves rolling acne scars. Like subcision, it addresses tethered rolling scars by promoting greater collagen and elastin deposition. However, the complete results may take 8 to 12 months to become visible, as new collagen is deposited gradually.

Through a combination of modalities such as chemical peels, laser treatments, PRP therapy, and the use of semi-permanent fillers or biostimulators, significant improvements can be achieved. It is essential to begin with early acne treatment to prevent scarring and address any erythema that may impede the healing process. With a patient-centered, multi-step approach that considers each individual's unique skin type and scar profile, we can achieve optimal cosmetic results and high patient satisfaction. My experience has shown that a tailored combination approach offers the best chance for significant and lasting improvement in the appearance of acne scars.

The insights and information shared in this blog are based on my personal experience and professional knowledge in treating acne scars. They are intended for informational purposes only and should not be considered as medical advice.

For personalized treatment plans and medical advice, please consult with a qualified healthcare professional. Individual results may vary, and it's important to discuss any treatment options with your healthcare provider.

Book your appointment here, myself and our team at AOKLINIK eagerly awaits the opportunity to serve you.

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