We at the Dermatology Institute have always placed the treatment and prevention of Acne Scars as one of our top priorities. We offer one of the most comprehensive list of options in the world, and in all skin color types. We have free cosmetic consults to discuss what options are best for you and to discuss the possible number of sessions needed.
Types of Acne Scars
Icepick scars appear as thin and deep ‘pitted’ scars. These are most common on the cheeks but can also appear on the forehead and temples.
Boxcar scars are broader but well-demarcated scars with steep, sharply defined edges.
Rolling Scars are broad depressions with gentle sloping edges, caused by scar tissue adhesions under the skin which pull down on the skin surface. These tend to be more noticeable when smiling or pinching the skin (unlike icepick or boxcar scars which are more superficial).
Atrophic scars are indented depressions in the skin caused by a loss of collagen. They are most common on the back or chest but can also occur on the face. Unlike other scar types, long-term color changes (lightening or reddening) may occur, especially on the chest and back.
Hypertrophic scars present as firm, raised, and sometimes contracted areas of skin, caused by excessive scar tissue developed during the healing process. These are most common on the chest and back but can occasionally occur on the face. They are often mistakenly referred to as keloids.
Treatments for Acne Scarring
Here at Dermatology Institute, acne scar treatment & prevention is one of our top priorities. We are proud to offer a comprehensive selection of treatment options, with personalized treatment plans available for every skin type and scar type.
Therapies available include:
Subcision: uses a needle or cannula underneath the surface of rolling or boxcar scars to release bands of fibrous scar tissue, freeing the skin from being tethered to deeper tissue layers.
CROSS (Chemical Reconstruction of Skin Scars): TCA or carbolic acid is applied directly into each scar to induce inflammation and stimulate new collagen formation, causing gradual reduction of scar depth.
Microneedling: uses a needling device to stimulate the formation of new collagen and improve the texture of all acne scar types.
Fractional Erbium or CO2 Ablative Resurfacing: ablates the skin surface and uses heat to stimulate new collagen development. Often used as a ‘finishing touch’ after other scar treatments are complete.
Peels: bring a fresh layer of new skin to the surface, softening the appearance of scars through rejuvenation of new collagen. Options range from minor spot treatments to full-face phenol peels (Dr Rullan’s 2-day croton oil/phenol chemabrasion procedure).
Dermal and Subcutaneous Fillers: 16 types of filler are available on hand to address all scar types and fill areas of lost collagen or fat. Best used after other scar treatments are complete, for more natural-looking results.
Intralesional Kenalog: injected into individual lesions to thin and smooth thickened or hypertrophic scars.
Some patients may need multiple types of treatment or several sessions of the same treatment to obtain the best results. Treatment packages are available for each of our procedures. Call us at 619-426-9600 for a free, personalized consult.
Here are the options based on stage of acne:
EARLY SCARRING WITH ACTIVE ACNE
*no downtime and can be done while on oral isotretinoin or antibiotics
- V-Beam perfecta non-ablative laser treatments for the red scars
- 30% Salicylic acid “peels or washes”
MILD SCARRING WITH ICE PICK, BOX SCARS
*Minimal down time
i. CROSS (chemical reconstruction of skin scars) with TCA or phenol
ii. Subcision with either 20 gage or 18 gage Nokor
iii. Above plus chemical peel with 3-Step Z.O. Peel or VI Precision
iv. Above plus Fractionated Erbium laser
v. Microneedling with/without CROSS
vi. DR. RULLAN’S TRIO FOR MILD SCARRING
MODERATE SCARRING WITH ICE PICK, BOX SCARS, ROLLING SCARS AND ATROPHIC OR HYPERTROPHIC SCARS
*3-7 Days Down Time
- Options i- ii above plus Fractional CO2, or
- Options i-ii above plus Blue Peel with TCA 20-26%
- Add Fillers ranging from Hyaluronic acids, to Bellafil, to Silikon 1000 for rolling or atrophic scars (shadow-enhanced scars)
SEVERE SCARRING WHERE > 50% OF THE FACE AND UPPER NECK HAS ALL SCAR TYPES LISTED ABOVE
*14 days down time
- CROSS, Subcision and Full-face 2-day modified Phenol peel
- Always consider addition of Fillers afterwards (such as Bellafill®)
- Hypertrophic scars need intra-lesional Kenalog and 5-FU and possibly V-Beam perfecta
- Touch-ups will be needed in areas with deepest scars
- Dr. Rullan’s 2-day Phenol Chemabrasion Peel
DI Publications & Testimonials
A Combination Approach to Treating Acne Scars in All Skin Types: Carbolic Chemical Reconstruction of Skin Scars, Blunt Bi-level Cannula Subcision, and Microneedling-A Case Series. J Clin Aesthet Dermatol. 2020 May;13(5):19-23. Epub 2020 May 1.
Summary of Dr Rullan’s acne scar regimen, from renowned Dermatologist Dr. Jashin Wu
When it comes to acne scars, Dr. Rullan emphasizes the concept of “defect-oriented therapy,” in which the choice of therapy depends on the specific type of scar. Ice pick scars are best treated with chemical reconstruction of skin scars (CROSS), which can be done with either trichloroacetic acid (TCA) 30-60-90-100% or carboxylic acid 88%. Dr. Rullan prefers the latter because it has less risk of scar widening. A cotton tip applicator or fine tip brush can be used for spot treatment of individual scars, and in his experience this treatment can be performed in all skin types with minimal risk of post-inflammatory hyperpigmentation. For rolling scars, he recommends subcision as the treatment of choice, with the goal of “breaking the tethers” under the skin. He uses an 18- or 22-gauge cannula rather than the Nokor needle. For boxcar scarring, multiple treatment options exist including CROSS, microneedling, fractionated erbium or CO2 laser resurfacing, and even 2-day phenol chemabrasion for more severe, generalized scarring. Finally, for atrophic scars, filler remains the preferred treatment.
Dr. Rullan utilizes a sequential combination regimen for acne scars in all skin types, as follows: 1) CROSS, 2) tumescent anesthesia (using 20-gauge spinal needle), 3) subcision, 4) microneedling or fractionated erbium or CO2 laser, and 5) fillers (after 2-4 sessions of steps 1-4). He repeats this regimen every 1-3 months, for a total of 2-4 treatments.