Acne scar types demand options

National report - Acne scarring is a multifaceted problem that may involve multimodal treatment, says Gerald N. Goldberg, M.D.

"Scarring from acne covers a broad spectrum of lesion types that include deep, narrow, sharply demarcated icepick defects; wider, dished-out, distensible atrophic lesions; and raised, erythematous hypertrophic scars," he says. "Individuals may present with a combination of those problems, and there is no one modality that is best to treat them all. Optimally, therefore, the treatment should be matched to the problem, and more than one approach may be used in any one patient."

Dr. Goldberg is associate clinical professor of dermatology and pediatrics, University of Arizona, Tucson.

Intralesional injections Intralesional injections can be useful to treat hypertrophic scars.

"Traditionally, those have been performed with triamcinolone, although now many clinicians prefer mixing the antimetabolite 5-fluorouracil with the corticosteroid, as it helps to break down the fibrosis," Dr. Goldberg says.

The vascular 595 nm pulsed dye laser (Vbeam, Candela) is another non-invasive alternative for improving the appearance of erythematous, hypertrophic and some atrophic scars. Treatment with this laser can improve the color, and also affects the pliability and thickness with repeated treatments. In addition, the pulsed dye laser is a viable choice for some pink, atrophic scars, for which it offers a modest effect on improving appearance through stimulating new collagen and improving the quality of the skin.

In the realm of nonablative laser resurfacing, the 1450 nm diode laser (Smoothbeam, Candela) represents one of the newer options. It has been approved recently for both the treatment of active acne and acne scarring, and in the latter indication can be used to improve the appearance of atrophic, distensible scars as well as hypertrophic lesions.

"However, patients must be counseled that this treatment requires four to six sessions that are repeated at monthly intervals, and improvement can, at times, be quite modest," Dr. Goldberg notes.

Other non-ablative modalities such as the 1320 nm infrared laser (e.g., CoolTouch3, CoolTouch; Profile, Sciton) have also been used for this purpose. The newer radiofrequency devices (e.g., Thermaget^®, ThermaCool^™ Syneron) are showing some initial promise in acne scar remodeling as well.

Surgical techniques Punch grafting and elliptical excision or punch excision with primary closure remain the most effective methods for treating icepick scars, and the punch grafting can be combined with a skin resurfacing technique to improve the final appearance of the grafted site.

These techniques can be done in a staged manner prior to more aggressive resurfacing, or at the same session along with dermabrasion or laser skin resurfacing with an ablative modality.Patients with more extensive scarring generally require more aggressive interventions. Dermabrasion has been the gold standard for many years, and it has stood the test of time as a safe and effective resurfacing treatment for all skin types, when performed with appropriate cautions. However, over the past decade, many dermatologist have replaced it with ablative lasers, notes Dr. Goldberg.

For ablative resurfacing, Dr. Goldberg uses both the erbium:YAG and CO₂ lasers. His choice is influenced partly by skin type, with the erbium:YAG preferred in darker-skinned individuals, as it causes less thermal injury and so is less likely to cause pigmentary changes. In, addition, it allows more controlled sculpting of the scar, but it penetrates less deeply than the CO₂ laser, he adds.

Risk issues The more aggressive resurfacing approaches are also accompanied by greater potential for complications, including increased scarring. Infection is possible, which can lead to scarring, and additional scarring can develop when using techniques associated with increased depth of injury. Darker-skinned persons are also at particular risk for pigmentary alterations.