Assessment and management of acne scarring

Victoria, Australia - Acne is the most common disease that dermatologists treat, affecting approximately 80 percent of adolescents.

According to one expert, it is critical to successfully contain and treat acne, because 95 percent of patients with acne longer than three years will develop lifelong acne scarring.

"Acne is a psychologically devastating disease, but it can be successfully treated with a wide range of therapeutic options, including antibiotics, hormonal therapy and isotretinoin," says Greg Goodman, M.D., director, Skin and Cancer Foundation and director, the Mohs micrographic surgery unit, Monash University, Victoria, Australia.

He offers a comprehensive review of the morphological classification of acne scars and current therapies that work best for each scar type.

Dr. Goodman says one type of macular scarring, erythematous scarring, likely indicates the angiogenic phase of wound healing, and is also seen on resolution of acne with treatment.

This is a stage of excess activity "where therapy should possibly be a bit more aggressive, with the use of vascular lasers, photorejuvenation devices as well as implementing anti-angiogenic therapy like retinoic acid, oestriol, diclofenac, calcipotriol and hydrocortisone. The aim is to shorten angiogenesis and discourage focal collagen breakdown," Dr. Goodman says.

"Most of these methods rely on collagen remodeling. These treatments involve initial wounding and subsequent repair with relayering collagen, initially thickened vertical correction, then maturation and contraction. Initially, all scars will increase until one to three months post-treatment. They eventually decrease over six months to two years with further remodeling," Dr. Goodman tells Dermatology Times.

He says low strength peels can include Jessner's, glycolic peels, less than 20 percent TCA and retinoic acid peels. Both infrared laser resurfacing (CO₂, erbium YAG) and dermabrasion are reasonable for scar treatment, but the side effects of dermabrasion may be too significant. Lasers, on the other hand, enable better vision. Difficult areas, such as the upper and lower eyelids, nose and lip vermillion, can be treated easily with fewer adverse events.

"Resurfacing lasers should be avoided on scars when there is a lack of appendages in the skin. This is the case in patients with a history of radiotherapy, large split skin grafts, extensive epilation, scar sheets, recent roaccutane therapy and active discoid lupus erythematosus," Dr. Goodman says.

Punch elevation works well when there are myriad punched out scars. This technique can be combined with resurfacing methods for even better cosmetic results.

Dr. Goodman uses the retroauricular skin for donor skin. It is crucial that the punch has sharp, straight walls and is slightly larger than the donor graft. After grafting, an erbium laser can be applied for four to eight weeks.