Acne scarring treatment options: Which is the best procedure?

Acne scarring is treatable with several modalities: laser, dermal fillers, fat transfer, radiofrequency, and skin needling. Each treatment is suited to different skin types and acne scar types. Read on for case studies and comprehensive information about the right acne scarring treatment choice for you.

Acne scarring treatment

Quick facts

  • There are various types of acne scars, each treated with different methods
  • Acne scarring treatments need to be matched to the patient’s acne scarring type, skin type, and recovery time permitted.
  • There are various types of acne scarring, classified based on their severity and morphology.
  • Treatment of acne scarring on olive or darker skin types carries the risk of post-inflammatory hyperpigmentation. Non-laser treatments carry less risk of this than laser treatments.
  • Laser treatments include laser resurfacing with the carbon dioxide laser or erbium lasers, or fractional laser treatment like the Fraxel or fractional CO2 lasers.
  • Non-laser treatments include the Infini radiofrequency needling, skin needling, and TCA CROSS.
  • Generally multiple treatments are required for the best results, and acne scarring can be improved in most cases but not completely resolved.

 What types of acne scars are there?

  • Macular scarring – this type of acne scarring is characterised by flat areas of increased and decreased pigmentation as a result of acne. Although there are not any indentations in the skin or raised scars, this is considered as a scar by many patients who have this problem.
  • Boxcar scars – these acne scars are superficial punched out scars that have sharp vertical edges on cross section, and can be round or oval shaped when seen from above.
  • Rolling scars – these acne scars appear as undulations in the skin and are usually caused by tethering of the skin to underlying structures
  • Deep divots – these are simply very deep scars that involve loss of subcutaneous tissue volume and result in a large divot.
  • Ice-pick scars – deep but small holes in the skin, similar to the indentation left by an ice-pick.
  • Hypertrophic scarring – where there is a raised and often pigmented scar as a result of acne.
  • Keloid scars – where the size of the scar is significantly raised, red/purple, and disproportionate to the size of the initial trauma caused by the acne

Grade 1

Macular scarring or flat scarring that is characterised by flat areas of increased or decreased pigmentation visible from greater than 50cm.

Grade 2

Mild disease that is visible at distances of less than 50cm and can be covered by make-up. Examples include mild rolling acne scars.

Grade 3

Moderate disease that is visible at 50cm or greater and is not easily covered with make-up or the normal shadow of a shaved beard hair. Stretching the skin can flatten the scar. Examples include more significant rolling scars, shallow boxcar scars, and mild to moderate hypertrophic scars.

Grade 4

Severe disease as in grade 3 but scarring is not flattened by stretching the skin. Examples include severe boxcar scars, deep divots, ice pick scars, and hypertrophic/keloid scarring (very raised/pigmented scars).

Acne commonly induces changes to skin pigmentation and skin tone. This occurs particularly on olive or darker skin types affected by acne. Hyperpigmentation can occur after trauma to the skin induced by an acne lesion. The hyperpigmentation that occurs is usually a result of inflammation caused from acne, and is called post-inflammatory hyperpigmentation. Hypopigmentation, or a loss of pigmentation,  can also occur as a result of acne, can often be permanent. Redness of the skin is common after an acne lesion has passed.
In many cases, these changes in skin pigmentation tend to resolve themselves with time, once the active acne has subsided. Often patients will want to expedite this process, as natural regression of this problem can often take more than a year. The key priority is to treat any active acne, and often using medical grade skin care can be helpful. Retinoids, or analogues of vitamin A, can help skin turnover and keratinisation (which can block pores) and reduce acne.  Using a non-comodogenic sunscreen can also help to reduce post-acne skin tone changes. Occasionally, a skin lightening agent can be used to help treat hyperpigmentation caused by acne also.
It is important to also address on the general quality of the skin as well as treating the acne scars per se. This helps to reduce the overall appearance of acne scarring.

Laser resurfacing (non-fractional) with a carbon dioxide laser and/or erbium laser is a method of treating acne scarring. These lasers ablate (remove via vapourisation) the top layer of skin and this results in growth of smoother new skin which lessens the appearance of scarring. Also, removing the top layer of skin effectively lowers the level of the ‘normal’ skin down to the level of the indented or atrophic acne scar to create more level skin surface. Laser resurfacing with these lasers not only addresses the issue of acne scars, but also can significantly improve the appearance of sun damaged (pigmented/wrinkled) skin. Although this is a very effective treatment, there is usually a two week recovery period associated with the procedure. Medicare rebates often apply for the treatment of facial acne scarring with a carbon dioxide or erbium laser.
A more recent advent in the treatment of acne scars are fractional lasers.  Instead of treating the whole skin surface, small columns of laser energy are fired into the skin, and the skin in between these columns is spared. This leads to faster healing times, and less risks and complications from treatment. One of the other key advantages of fractional lasers is their ability to penetrate deeper into the skin than non-fractional lasers. By doing so, these lasers are able to effectively stimulate the production of new collagen. This raises indented or atrophic scars to the level of the normal skin, as opposed to non-fractional resurfacing which shaves the layer of the normal skin down.
One of the first fractional lasers used was the Fraxel laser. This is classified as a non-ablative laser, that is, it does not vapourise any tissue, but instead heats columns of tissue with laser energy. It is this heat energy that stimulates new collagen production in the skin.

Fractional carbon dioxide lasers have been an even more recent development that can provide superior results to Fraxel treatments. Fractional carbon dioxide lasers are ablative lasers, that is, they vapourise columns of skin as well as heat the skin. By ablating as well as heating the tissues, more collagen stimulation and new skin formation occurs and it is possible to achieve superior results to non-ablative lasers like the Fraxel. At Victorian Cosmetic Institute we use the Lumenis Ultrapulse fractional carbon dioxide laser with the Deep Fx hand piece for the treatment of acne scars. This handpiece fires very fine columns of laser energy deep into the skin with only a small percentage of the skin’s surface being affected. The recovery period from fractional carbon dioxide laser treatment ranges from 3 to 10 days depending on the intensity of the treatment. The results from fractional carbon dioxide lasers are particularly effective in the treatment of acne scarring in fair skin types. For olive or darker skin types, there may be an increased risk of post-inflammatory hyperpigmentation (darkening of the skin post treatment), and for these skin types, we recommend Infini radiofrequency needling treatments.

Our Medlite q-switched Nd:YAG laser, which is used also for tattoo removal and pigmentation removal, can also be used at settings to help promote collagen production and help improve mild superficial acne scarring to help raise small indentations in the skin. The advantage of this treatment is that it has only a small amount of downtime in comparison to the above treatments, however multiple treatments need to be performed. Usually, several treatments are required. There have been clinical studies showing the effect of this laser on flattening the topography of scarred skin, and a general overall improvement in skin texture and smoothness. Generally, this treatment is very mild, and not particularly effective in the treatment of acne scarring.

Surgical skin needling is an older but very effective method of treating superficial acne scars by puncturing the skin with multiple fine 3mm (long) needles attached to a small rolling pin. This stimulates collagen production and helps to lift up any ‘indented’ or atrophic acne scars. The advantage of this treatment is the fact that it can be used on all skin types including olive and dark skin types. People of Asian, Indian, African, and European background are able to have this treatment with less risk pigmentation changes in comparison to laser treatments post-needling. Also, it penetrates very deeply so that collagen can be stimulated on deeper acne scars. Usually it takes 3 to 7 days to recover from the treatment, depending on the degree of the treatment.

Micro-needling is another form of skin needling that utilises fine needles attached to a stamping device that oscillates up and down to create thousands of micro-injuries to the skin. It generally is a lot less invasive than surgical skin needling (described above), and although it has less downtime, generally requires more treatments to achieve similar results.

Infini is a non-laser treatment that combines both micro-needling with radiofrequency. It is an effective treatment for acne scarring as well as skin tightening, and is particularly suited to olive or darker skin types. It has a lower risk of post-inflammatory hyperpigmentation than laser treatments, and the recovery time is significantly less than surgical skin needling.

TCA CROSS is a simple yet effective method of improving acne scarring. It is most commonly used for small indented acne scars. It involves careful placement of high concentrations of trichloroacetic acid into the scar with a toothpick. This stimulates the production of new collagen and remodelling of existing collagen to fill in the acne scar. The advantage of this treatment is that it is localised to the problem only and not the unaffected skin.

Subcision is another technique that is suitable for treating depressed acne scars. The size of the scar usually needs to be fairly large or deep. It involves putting a special needle under the depressed scar. Often acne scars are depressed because the skin is tethered to the underlying tissues

Chemical peels are another method of treating more superficial acne scarring. Generally, medium to deep chemical peels are required to achieve a significant result, but a series of more superficial chemical peels could help achieve some improvement in milder acne scarring without significant downtime.

Microdermabrasion is a technique that can also help, but only extremely slightly, with mild acne scarring. It uses a gentle vacuum to bring your skin in contact with a diamond-coated head that gently abrades the top layer of dead skin. This stimulates collagen production and helps with scarring. Generally, more than 10 treatments are required and the results are usually slight, and certainly a lot less dramatic than the other treatments mentioned here. There is virtually no downtime with microdermabrasion, although there may be some redness that persists for a few hours.

In many cases, volume loss occurs under the skin as a result of acne, in particular cystic acne. Replacing volume can aid in the treatment of acne scarring.

Dermal fillers are a quick and effective means of replacing volume loss to improve acne scarring. By injecting these dermal fillers underneath scarring, they help to replace lost volume, and lift the skin towards its normal level.

Alternately, fat can be transferred from the abdomen, hips or thighs, and be injected underneath the areas of scarring. As well as providing additional volume to the area, fat contains stem cells which help in the skin regeneration process. Fat transfer can be combined with treatments such as skin needling or laser treatments in the same session to synergise the treatments.

TABLE: Comparison of various treatments for acne scarring

Name of treatment Effectiveness Recovery period Number of treatments required Cost Risk Comments
Dermal fillers +++ + ongoing +++ + Temporary only
Dermabrasion +++ +++++ + +++++ +++++ Antiquated. Very risky and prolonged recovery
Fully ablative laser resurfacing with carbon dioxide laser and/or erbium laser +++++ +++++ + +++++ +++++ Can result in loss of pigmentation (hypopigmentation). Also effective for general improvements in skin and sun damage.
Infini Radiofrequency needling +++++ ++ ++ +++ ++ Particularly suited to olive or darker skin types.
Fraxel 1550nm + +++ ++++ +++1/2 ++ Not as effective as fractional carbon dioxide with similar recovery periods
Fractional carbon dioxide laser +++++ +++ ++ +++ +++ A good balance between recovery period and results
Portrait plasma skin regeneration ++ ++++ ++ +++++ +++ Prolonged downtime relative to results achieved.
Surgical skin needling ++++ ++++ ++ ++++ +++ Excellent results, but prolonged recovery times in comparison to fractional carbon dioxide or Infini RF needling.
TCA CROSS ++++ +++ +++ + +++ Effective and cheap
Subcision +++ +++ +++ + ++ For deeper scars
Medlite (q-switched Nd:YAG) laser + + +++++ ++ + Minimal or no downtime. Multiple sessions essential
Superficial Chemical peels + + +++++ + + Minimal downtime. May only make a slight improvement
Microdermabrasion + 1/2 +++++ ++ + A light treatment. Likely to result in no improvements
Medium to deep chemical peels ++ ++++ ++ +++ +++ or more for deeper peels Similar to Portrait plasma, but cheaper

 

Although there have been many advances in the treatment of acne scarring, it remains a difficult skin concern to correct. In most cases, an improvement is achieved, but due to the nature of the problem (scarring), it is not possible to completely remove scarring in most cases.

Most of the treatments described require multiple treatments to achieve the best result. Each treatment stimulates remodelling of the skin’s collagen, and to get the best results. As a general rule, we allow 2 months as a minimum period between treatments. This time interval between treatments is a balance between the time required for new collagen to form and the patient’s desires to achieve results quickly. New collagen formation can occur for up to 1 year post treatment, but patients are usually reluctant to wait a full year prior to deciding to retreat.

There are many factors when deciding what treatment to use when treating acne scarring. Our doctors are highly experienced in the treatment of acne scarring, and will be able to help you decide which treatment best suits you and your skin condition/type.

A consultation with one of our doctors will help assist you in your decision about which treatment will best suit your goals and lifestyle. Due to the large number of treatments available, a consultation will help you decide which best treatment suits you. As a rule of thumb, the more invasive the treatment, the greater the downtime, and the greater the improvement.

The first step is simply contacting us for your initial skin consultation, where we will discuss with you what is a realistic and achievable outcome, and what to expect from your treatment.

Dr. Gavin Chan
Dr. Gavin Chan

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