Scar type influences treatment selection

Palm Desert, Calif. - Acne scar treatment using multiple surgical modalities applied in a sequential manner and individualized to the acne scar yields results superior to those achieved with just one technique.

This type of defect-oriented treatment, dermatologist Christopher B. Harmon, M.D., says, relies on first categorizing the scar as an ice pick, boxcar or rolling scar.

The real step forward in acne scar management, Dr. Harmon says, is the use of multiple modalities - as dictated by the acne scar type - to achieve the greatest improvement in patients with the least amount of risk and down time.

"This can usually be accomplished by a series of treatments done every four to six weeks often leading up to an ablative resurfacing as the final treatment," Dr. Harmon says.

Incisional, excisional modalities

Ice pick scars and boxcar scars are best treated with a combination of incisional surgery, trichloracetic acid (TCA) and punch grafting, as well as wire brush dermabrasion or CO₂ laser plus dermabrasion. Rolling scars, best described as distensible, soft-shouldered scars, respond best to subcision, radiofrequency, non-ablative lasers, fillers, thread lifting and CO₂ laser resurfacing.

"Because ice pick scars are very deep, the best treatment is often excising the scar whether by cutting it out and sewing it together or by punch floating or punch grafting," Dr. Harmon says.

He also recommends a new technique - called the TCA cross technique - for ice pick scars. This technique uses 60 percent to 95 percent trichloracetic acid to produce a scar within the ice pick scar to fill it in. (Lee JB, Chung WJ, Kwahck H, Lee KH. Focal treatment of acne scars with tricholoracetic acid: chemical reconstruction of acne scars method. Dermatol Surg 2002;28:1017-1021). These treatments are done every two to four weeks for three to four sessions.

Rolling scars seem to be most improved by subcision, a technique which employs a tri-beveled 16 to 30 gauge hypodermic needle applied in a rasping motion parallel to the underside of the dermis. This technique has been reported to provide 50 percent to 60 percent improvement (Alam M et al. Subcision for Acne Scarring: technique and outcomes in 40 patients. Dermatol Surg 2005:31:310-317).

Dermal grafts and even autologous fat transplants are effective additions to subcision for treating rolling scars.

"Anything that enables the 'soft shoulders' of the rolling scar to come up works well," Dr. Harmon says, "including bleeding from the subcision, which sometimes causes a blood clot underneath what's just been released causing it to be elevated and preventing it from collapsing."

Nonablative treatment

Nonablative treatments that Dr. Harmon recommends for rolling scars include radiofrequency and mid-infrared lasers with wavelengths of 1,350 nanometers to 1,450 nanometers. The mechanism of action for monopolar radiofrequency (RF) on dermal collagen contraction and remodeling is well known and documented in peer-reviewed publications, Dr. Harmon points out. RF results in collagen regeneration and sebaceous gland heating, which, in turn, provides acne scarring improvements and gland size reduction.

"Enhanced fibroplasia and keratinocyte turnover rates may contribute to comedone count reductions, as well," Dr. Harmon adds.

Rolling scars oftentimes can be improved by filler substances.

"Some types - like collagen - have been around for a long time and are still hard to beat," Dr. Harmon says. "They're simple and easy to apply and they correct the defects. The downside is they only last four to six months."

Sculptra (Dermik), he points out, works well for middle aged or older patients whose acne scars become more noticeable as their skin becomes lax.

"If you replace that lost volume with a volume replacement filler it distends the skin and stretches out the acne scars and makes them go away. The downside, again, is that this lasts only about six months," he says.

Silicone, autologous fat transfers and dermal grafts all potentially offer longer lasting benefits and all are options for acne scars, as well.