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Years after outgrowing adolescent acne, the aftermath – acne scars - persist. Advances in acne therapy and dermatologic surgery have made it unnecessary for acne patients, both current and past to endure acne scarring. An Ounce Of Prevention… Prevention may sound like a glib answer to how to handle acne scars. But since an estimated ten million Americans become scarred to some extent by acne each year, intervention is the absolute best solution. Who will develop acne scars and how severe will scarring be? Short of a crystal ball, much of that is left to chance. What we do know is that genetics plays a definite role in the likelihood of acne severity and consequent scar formation. Also, acne severity has been linked to a more severe form of scarring later in adolescence or adulthood. Because 95% of acne patients will develop scarring to some degree, the earlier that treatment appropriate for the severity of the outbreak is initiated, the better the odds are that scar formation will be mild. Delaying acne therapy by 3 or more years is likely to increase one’s risk of more significant acne scarring. For the lucky majority, acne scarring is a minor annoyance, difficult for others to visualize. For others, acne scarring can cause devastating long term emotional suffering in its victims. Teens may deal with depression, become withdrawn and a loss of self confidence. In fact, acne scarring has been cited as a risk factor for male suicide. Newer acne therapies make it needless for anyone to suffer from acne or go on to form scars. Early medical intervention is key to preventing unnecessary disfigurement. While this doesn’t mean that everyone suffering a single blemish should rush to schedule an appointment with a dermatologist, I can’t stress enough that acne unresponsive to OTC therapy options should be evaluated by a specialist. PIH – The Great Fake Out I lost count long ago of the number of acne patients returning for their initial 6 to 8 week follow-up concerned about their new acne scars when in actuality there wasn’t a scar in site. What they were really noticing was color change. This post inflammatory hyperpigmentation (PIH) is not an acne scar. It is the normal remnant of the skin’s inflammatory process. For those with pale skin tones, this aftermath color change is usually pink, red or purple in color. Patients with darker skin tones may notice brown or black spots where their acne once was. PIH can fade unassisted. Unfortunately, the darker the PIH, the longer it may take to resolve. It may also require some intervention in order to hasten the process. While PIH is not a true scar, when it lasts past a year, it certainly seems like a permanent problem. Hydroquinone is helpful for treating newly healed wounds and resolving acne, helping hasten the resolution of reddened spots. Although Hydroquinone is a gel base that should not flare your acne, it is important not to apply it too generously, as acne prone skin may not tolerate any product smothering the skin. There is no point in aggravating your acne in the attempt to eradicate the discoloration. For areas that are brown in nature, the use of bleach, usually with hydroquinone may be incorporated into an acne and skincare regimen. Prescription hydroquinone and glycolic acid bleaches like Glyquin and Lustra AF are highly effective in resolving undesirable skin discoloration. Glyquin contains a higher percentage of glycolic acid and is free of the irritant metabisulfite. Both contain an SPF. Other advanced skincare solutions contain 2 percent Salicylic Acid and should be used one to three times per week to reduce the appearance of post-acne marks with regular use. Using a treatment to help with discoloration will need to be used consistently over time for best results. Sun avoidance is crucial for many reasons, but when waiting out the fade-game, an oil-free, oil-reducing sunscreen – like our Neostrata or Obagi line of products goes a long way Ultraviolet light will darken the skin, preferentially darkening areas of abnormal discoloration. Sun protection prevents this process, allowing bleaching treatments to work without interruption. Cause And Effect As an acne cyst forms, the neck of the sebaceous gland expands, filling with bacteria, cells and sebum that are unable to pass through to the skin’s surface. Eventually the cyst ruptures this "foreign matter" deep within the dermis, quickly attacked by white blood cells responsible for fighting infection. All acne scars are not alike. A forceful inflammatory response can have two results. The most common outcome is loss of tissue as collagen is destroyed. Skin overlying the collapse of the area is provided no support and a soft saucer-shaped depression (aka pock mark) or jagged ice pick scar is formed. This is more typical on the face and is seen in both men and women. Less frequently excessive scar tissue (keloid) is formed as fibroblasts (the dermal cells which produce collagen) are triggered. This is more commonly seen on the male torso. Patients are often surprised to discover that another skin change is in fact a form of acne scarring. Tiny firm white bumps surrounding hair follicles on the upper arms or upper torso are known as follicular macular atrophy. These scars can last indefinitely. Aging can affect scar visibility. After the age of 40, 1% of the dermal collagen is lost annually. With this additional loss of collagen combined with reduced skin tone, scars can become far more noticeable. Treatments Nobody wants to miss out on the "best" treatment. But when it comes to treating acne scars, there is often no single "best" solution that applies to an individual or to every acne scar. Differences in location, depth, size and number of scars all affect treatment decisions. What is your perception of the scars? Do they cause great anxiety or is this something that you’d simply like to improve if possible? These questions along with cost, your expectations and the amount of effort you plan to devote to the treatment will also be factored into the decision making by the physician. Luckily there are a number of new procedures now available that compliment or surpass previous scar revision techniques. Individually designing a program aimed at the patient’s unique situation will help maximize improvement. Laser Treatments There are 2 major categories of laser used in acne scar therapy. They are the resurfacing (aka ablative) lasers and the non-ablative lasers. Ablative lasers literally remove the outer layers of the skin, burning away scar tissue and stimulating the dermal collagen to tighten, reducing the amount of scar visibility. The ultrapulsed carbon dioxide laser and erbium YAG laser are most frequently used in laser resurfacing. Because the skin is injured and unprotected tissue exposed, great effort must be put into wound care and infection prevention. The skin may remain reddened for several months or a year afterwards. Non-ablative lasers trigger changes within the dermis without injuring the epidermis. They are the "lunchtime" form of laser therapy. Smoothbeam is the newest FDA approved laser for this treatment. Smoothbeam targets and heats the sebaceous gland, helping reduce sebum and acne formation. Heating the collagen helps tighten the dermis, resulting in less visible scarring. Another option is the yellow pulse dye laser. The yellow light laser also helps treat keloidal scars, flattening and reducing redness as well as helping control itching of the raised scar. The surface of the skin is cooled to prevent the laser from damaging the epidermis. A patient will feel both the cold spray as well as some amount of stinging and heat during the session. The application of a topical anesthetic an hour before the procedure makes this tolerable. The procedure takes about an hour. Typically 3 sessions a month apart are performed. Another non-ablative laser, the N-Lite is used to trigger collagen formation. Three or more treatments may also be required to obtain acceptable improvement. Filler Substances
Filler substances are best used for shallow, saucer-shaped acne scars. The market has seen an increase in the number and ever improving quality of filler substances used to help "plump up" acne scars. Restylane, Cosmoderm, Cymetra, Fasciian, Artecoll and bovine Collagen are all available. Hylaform is one of the newest fillers just recently approved by the FDA. Fat transplantation utilizes a patient’s own fat removed by a small liposuction cannula, prepared and reinjected into the dermal defect. While none of these methods are permanent, results tend to last between 3 and 6 month. Punch Excision
Ice pick acne scars have hard, irregular jagged borders and often the depth is irregular as well. Simple excision of these scars with a sutured closure allows the dermatologist to bring the dermis back together, get rid of the ragged margins and close the area with a fine, uniform line. The tiny linear scar may be allowed to fade on its own or the procedure may be performed before a more generalized resurfacing is performed such as dermabrasion, microdermabrasion, chemical peel or laser resurfacing. Subcision
In this procedure the dermatologist undermines the acne scar with a sharp instrument such as a tiny scalpel or needle. Subcision helps break fibrous bands of scar tissue that are creating tension between the epidermis and deeper structures and also helps induce new collagen formation. Dermabrasion
Dermatologists have been performing dermabrasion for decades. This procedure has fallen somewhat out of favor with the availability of newer, easier to use techniques. In dermabrasion, the skin is anesthetized and frozen and an extremely sharp rapidly rotating blade sheers away damaged tissue. The ultimate result is similar to laser resurfacing. Microdermabrasion
Microdermabrasion is not a substitute for traditional dermabrasion, which may still be required for advanced cases of ice pick acne scarring. Recent studies confirm that microscopic exam of treated tissue shows significant improvement. This procedure is also done as a series in an outpatient setting, usually the physician’s office or even some day spas. The combination of topical products can help expedite this procedure as well. Chemical Peels
A chemical peel involves the application of a high potency acid upon the skin. The more potent the acid, the deeper the penetration into the skin. Personally I find this more beneficial for post inflammatory skin color changes and the most minor of acne scars. Ultra aggressive phenol peels which reach the deeper dermis must be approached with great care and administered in a hospital-like monitored setting because they have been associated with heart arrhythmias.
Topicals For Atrophic Scars
Everyone always wants to know what topicals can help acne scars. Certainly anything that has been shown to help stimulate collagen bundle formation such as Hi Potency Serum Vitamin C which is oil-free and/or the use of a topical Vitamin A derivative such as Retin A or Tazorac (help with exfoliation as well as stimulate collagen) seem like logical choices. Vitamin C and the topical Vitamin A product should be used at separate times of the day. These are certainly options I do encourage those with acne scars to take. I do think that the reality is that a procedure is going to maximize your results, whether done alone or incorporated with a topical agent.
Keloid Scar Therapy
Keloids are never easy to treat. However, a variety of options continue to come to the market. Pressure dressings and massage may help fatten some keloids but is not considered a terribly effective form of treatment. Silicone based topicals are en vogue. Steroid creams, injections and impregnated tapes can also be beneficial for treating keloidal scars. Cortisone helps shrink thickened, raised fibrous scar tissue. The pulse dye yellow light laser as mentioned above is useful in keloid therapy. Finally, Interferon injections can help soften a keloid and smooth it out. Acne scarring is no longer a problem without a solution. All of the techniques I described have become invaluable treatments for patients seeking to eradicate acne scarring. But never forget, scarring is preventable. Don’t put off acne therapy. The earlier it’s dealt with, the less likely acne scars will be in your future. Prevention is the best and most effective form of treatment. |
