Acne scars
Scarring can be prevented with early, effective treatment of moderate to severe acne.
Do acne scars make you want to hide?
A scar is a permanent mark left after the healing of an injury or disease process.
Damage to the surface and underlying layers of the skin can be extensive, following moderate to severe acne. This can result in flat or thick raised scars, discolouration and pitted, indented skin.
Some scars improve over time, others remain unchanged and some can continue to worsen with time.
While some scars can be disguised with makeup, scars remain a permanent reminder of previous acne.
If there is a family history of scarring acne, early treatment and review by a dermatologist should be considered.
Picking or squeezing of pimples can also be a cause of scarring.
Different scars require different treatments. Some of the treatment options for scarring include:
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New ways to remove acne scars
Fraxel laser
In the future, Fraxel laser may be regarded as the "new gold standard" for treating acne scarring.
The Fraxel laser gets down very deep into the skin to stimulate a healing and smoothing response, without actually creating an open wound.
Fraxel is an erbium-glass laser that works by putting pixels of energy into the skin, rather than vaporising the surface (as traditional laser resurfacing has done).
It therefore doesn't create a wound, although there is some swelling and redness after the procedure; the majority of which goes in few days.
A series of Fraxel laser procedures is required and the skin continues to improve over at least six months afterwards.
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Skin resurfacing
Carbon dioxide or Erbium lasers are used on a variety of scars to carefully remove a controlled amount of the damaged outer layer of skin. It leads to the repair of the surface layers and can stimulate new collagen formation. Collagen provides structure and strength to our skin.
Skin resurfacing can soften the scar, even out discolouration and produce a smoother and tighter appearance
For acne scarring, lasers have largely replaced earlier resurfacing techniques such as chemical peels and dermabrasion.
New treatments using "non-ablative" lasers to stimulate new collagen production do not damage the top layer of the skin and may be used for soft, indented scars.
Plasma resurfacing
Plasma resurfacing seems to not produce the hypopigmentation (bleaching) associated with resurfacing with lasers and deep peels.
Plasma resurfacing uses high-energy nitrogen plasma to cause the top layers of skin to shed and create a new surface for the skin.
Unlike laser resurfacing, the old skin surface stays in place until the new layer grows underneath, so no open wound is created (unless it is scratched off). The new skin continues to transform for months afterwards.
The new collagen formation has a more natural layout compared to that following laser resurfacing and peels.
To date, there has been no incidence of hypopigmentation of the skin, which had been a significant problem with the sort of deep resurfacing required to treat acne scarring.
Fractional laser treatment
Fractional laser treatment, sometimes also known as fractional resurfacing or "Fraxel" is a treatment for improving skin texture and blending-in imperfections such as acne scarring.
Beams of laser light penetrate pixel-fashion very deeply into the skin causing remodelling in all layers down to the depths of the scars. A series of treatments is required, each causing redness and swelling for up to a week. The skin surface is not removed, unlike previous laser resurfacing techniques, so no dressings or special ointments or skin care is required. Regional treatments are also possible as the skin is not abnormally lightened as can occur with other resurfacing techniques.
The treatment is usually conducted after anaesthetic cream has been applied for quite some time (over an hour) or local anaesthetic has been injected.
Photodynamic therapy
Photodynamic therapy or PDT is a treatment which is most usually employed for treating superficial skin cancers and precancerous lesions; however it may also be used for treating acne and some inflammatory skin conditions.
After a microdermabrasion treatment which removes cell build-up from the skin's surface, a solution containing a special solution or cream containing aminolevulinic acid (ALA - an amino acid - building block of protein) is applied to the skin for about an hour. This is taken up more readily by the inflammatory cells and oil-producing glands and makes them more sensitive to light.
After this incubation time, light is applied to the area. This is usually a continuous blue or red light but may be an intense pulsed light or a laser. As the acne areas will have taken up the ALA more than the normal skin, they will be selectively treated. These areas usually flare up for a week or so and then settle. A series of treatments is usually required.
The normal skin surrounding the acne areas becomes sensitive to light for the following two days, so this means that bright light needs to be kept off the area during this time. For body areas, clothing is usually sufficient to do this, however for the face, it usually means staying indoors and keeping away from TV and computer screens and windows where the sun shines in.
This procedure is quite expensive so is usually not considered as a first option.
Micordermabrasion
This is a treatment that gives the skin a "cut and polish and a vacuum clean". It has a superficial "buffing" effect which smooths the surface and the suction cleans out comedones and pustules. A series of treatments is usually performed.
For acne, it is not regarded as a stand-alone treatment but may be used in association with topical or oral medications.
For acne scarring, it would only be considered for the most minor of conditions.
Fillers/Implants
Indented scars can be plumped out with commercial products injected into the skin.
Hyaluronic acid (Restylane and Juvederm) has largely replaced collagen because of its longer lasting benefits.
Fat cells and tissue grafts can also be transferred from another part of the body.
However, these techniques do not result in a permanent improvement and may have to be repeated or touched up.
Steroids
Raised and thickened scars may be softened and flattened by the use of steroids either applied to the surface of the skin or more commonly injected into the scar.
Recently, fluorouracil (an anticancer drug) has been successfully used to flatten scars by being injected into the scar.
Surgery
Deep "punched out" scars can be cut out and closed side to side with stitches, while large raised scars may be improved by surgically removing them. Surgery may be performed prior to laser resurfacing which can sometimes help blend in and hide the surgical scars.
Subcision or freeing up of an indented scar is a valuable procedure when the scar is bound down to underlying tissues. Other so called 'punch' techniques include punch grafts - where a small graft is used to replace the scar or punch elevation - where the scar is punched and lifted up to a higher position in the skin.
Blue light therapy
Narrow band blue light phototherapy is well known as a method of reducing jaundice in newborn babies. Now it is seen also as having a promising role in treating mild to moderate acne but from a medical and scientific viewpoint, blue light therapy remains an understudied, investigational acne treatment, ie - more research is required to demonstrate it has a proven safety track record and identify its long-term effects.
How it works
Blue light therapy involves directly exposing the entire skin area affected by acne to either a continuous or intense pulsed light which has been shown to have anti-bacterial and anti-inflammatory effects. A typical treatment requires two sessions per week over four to five weeks.
It is rare for blue light to be used in isolation and it is usually combined with either topical or oral medications. Some blue light devices also use a radiofrequency current which is thought to get a little deeper into the skin and have greater affects on the sebaceous (oil) glands.
Sometimes blue or other lights are used in conjunction with another topically applied medicine which increases the sensitivity of the acne lesions to the effects of the light. This is called photodynamic therapy (PDT). However, PDT makes the skin extremely sensitive to light for the following two days, so it means staying indoors away from bright lights for this time.
Study findings - risks and benefits
The limited studies conducted to date for blue light therapy suggest it is more likely to have a role for controlling an acne flare in an adult with mild to moderate acne. These studies observed that by four weeks into treatment, the majority of people with mild to moderate acne noticed some degree of improvement in their acne.
Inflammatory acne lesions (red raised and/or pustular pimples) are reduced more than blackheads and whiteheads. In some cases, acne was reported to completely clear.
However, about one in five people will see no benefit from four weeks of treatment and may even see their acne worsen in severity.
Blue light therapy does not appear to produce extended acne remissions. In one study, the benefits of a topical antibiotic treatment were greater than those for blue light therapy four weeks after stopping treatment.
There is very limited safety data regarding blue light. They come from a few controlled studies which followed only a very small number of patients over a relatively short treatment course (e.g. eight treatment sessions over four weeks).
The results of one study suggest blue light therapy should be avoided in severe forms of acne because it was observed to worsen patients' acne after starting treatment.
As with any therapy, there are risks involved. Unfortunately, there is only limited information about the short-term side effects and risks with even less known about blue light's longer-term safety.
Short-term side effects
During treatment and in the weeks following therapy, some people will be affected briefly by:
- Redness and swelling of treated areas
- Skin dryness
- Skin pigment changes (uneven or blotchy increase in skin pigment)
- Worsening of acne (possibly more likely to occur in people with severe acne)
- Photosensitivity (sensitivity to light)
Long-term side effects
Sunlight is known to have a number of harmful effects on the skin which can be delayed for years or decades after excessive exposure.Although there is no data on the long-term skin effects of repeated exposure to intense blue light, potential concerns include:
- It may contribute to skin cancer risk.
- It may cause photo-ageing of the skin.
- It may suppress the skin's immune system.
Points to consider
When choosing an acne treatment, look at what is known about the long-term safety and risks of each therapy. Acne affects 85 per cent of Australians aged 15-24 years and can continue for many years, with many females still affected in their 30s and 40s, so safety is paramount in the treatment of acne in an otherwise young and healthy individual who may need to continue treatment for many years.
Acne control programs need to be individualised - one size does not fit all. First line acne strategies should be based on effective, proven treatment strategies and therefore until more is known about blue light therapy, it should not be used as a first line treatment for acne.
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