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.
Summary by renowned Dermatologist Dr. Jashin Wu, of Dr Rullan’s Acne Scar regimen
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.
Types of Acne Scars
Icepick scars appear as thin and deep ‘pitted scars’. These are most common on the cheeks however can appear on the forehead and temples as well.
Boxcar scars are broader but well demarcated scars with steep, sharply defined edges.
Rolling Scars are similarly broad depressions such as boxcar scars but have more gentle sloping edges. Rolling scars are due to 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 most commonly found on the back or chest but can also occur on the face. Atrophic scars are due to a loss of collagen in the area of the scar, leading to depression of the skin. Unlike other types of acne scarring, long-term color changes (lightening or reddening) of the area within the scar may be noted with atrophic scars, especially on the chest and back.
Hypertrophic scars are due to excessive scar tissue which develops during the healing process. Commonly referred to as keloids (incorrectly) hypertrophic scars present as , firm, raised, and sometimes contracted areas of skin. Like atrophic scars these are most common on the chest and back but can occasionally occur on the face. These are typically treated with steroid injections and laser treatment to reduce thickness and associated erythema (redness).
Treatments for Acne Scarring
PHENOL CROSS / TCA CROSS
CROSS (Chemical Reconstitution of Skin Scars) is a technique which uses the principles of chemical peeling applied to acne scars. This treatment, which is most effective for icepick scarring, involves the application of 50-100% Trichloroacetic acid (TCA) or Phenol (88% Carbolic Acid), both of which are very powerful chemical peeling agents, directly to the base of ice-pick scars. This causes an intense and highly focused chemical peel at the base of the scar, stimulating the formation of new collagen leading to a reduction of scar depth over time. This is a quick and well tolerated treatment for icepick scarring with minimal to no downtime. CROSS treatments are performed every weeks and generally 5-6 sessions are recommended to reduce the depth of icepick scars prior to ablative or non-ablative laser treatments.
Acne Scar Subcision (with Cannula)
Subcision is a tried and true method for the treatment of rolling scars and some boxcar scars. This technique relies upon the theory that many depressed acne scars, specifically rolling scars, are due to vertical collagen adhesions which develop between layers of collagen and collagen and the subcutaneous fat during the healing process of cystic acne. Subcision involves entering the skin adjacent to a rolling or large boxcar scar with a specialized needle or cannula and cutting/releasing these fibrous scar tissue bands, reducing adhesion of the skin surface to deeper tissue layers and smoothing the skin surface. Swelling and bruising for 4-7 days are common after treatment. While subcision is a highly effective standalone treatment for rolling scars when performed as a treatment series, a more effective approach we recently developed is to perform subcision with a blunt cannula followed immediately by injection of a biostimulatory filler such as sculptra. This combination therapy reduces the total number of treatments as well as the downtime associated with serial needle subcisions.
Microneedling for Acne Scars
Microneedling utilizes a device to directly injure scars underneath the skin surface and stimulate the formation of new collagen and improve the texture of all types of acne scars. There is no heat-related inflammation which makes it useful when treating Asian skin and darker skin types which are prone to hyperpigmentation from laser based treatments. Generally 4 treatments spaced 1 month apart are recommended for each treatment course. Side effects from treatment include redness and mild to moderate swelling of the treated area which resolves in 2-3 days.
Fractional Erbium or CO2 Ablative Resurfacing for Acne Scars
Fractional Erbium or CO2 resurfacing for acne scars utilizes a laser which both ablates (vaporizes) the skin surface while simultaneously delivering heat energy into the subsurface of the skin to stimulate new collagen development. Fractional resurfacing is best utilized as a ‘finishing touch’ after other scar specific treatments such as CROSS, Subcision, or Microneedling have been performed. This treatment can provide both smoothing of subtle acne scars along with significant improvement in overlying skin tone and superficial texture. Downtime of around 1 weeks is expected.
Dermal and Subcutaneous Fillers for Acne Scars
Dr. Rullan can choose among 16 different fillers to correct Atrophic scars. Superficial scars (divots) are due to loss of collagen in the dermis, and these can be treated with Hyaluronic acid fillers (such as Juvederm or Restylane). Acne can also destroy subcutaneous tissue like fat, resulting in concave areas on the temples or cheeks. For these, volumetric fillers or biostimulatory fillers can be used ( Sculptra, Bellafill, Fat and Silicone). Fillers are best used after acne scars have been changed by the other modalities listed, so that they have become distensable and with soft shoulders. This allows the filler to correct the scar more naturally and without causing a “doughnut-shaped” effect. Fillers help soften the effect of lighting and “shadows” which can accentuate the scars. Even temporary fillers last longer in acne scars and can help “stretch out” some difficult surface scars.
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