Dr. Caren Campbell, MD, in her San Francisco office
Source: Ashley Batx
Acne scarring affects the pores of so many who have long since recovered from active acne. With the recent advent of laser technology and dermatological research, much progress has been made in understanding how to better care for patients during treatment and in improving its effectiveness.
I recently discussed the issue with the leading dermatologist in San Francisco, Dr. Caren Campbell, M.D., a doctor who has treated many Millennium professionals in the area struggling to eliminate acne scars. He then shares the recent and remarkable progress that has been made in the treatment options to heal acne, how to know if the scars will disappear on their own, when to seek medical intervention and the questions to ask their doctor.
First, what causes acne scars?
Campbell: Acne scars are the result of cystic and inflamed acne lesions. When the inflamed and clogged pore is broken, the attempt to repair broken skin is not as perfect as the original skin. Depending on the depth of the broken pore, various types of acne scars can occur: atrophic, ice pick, van, rolling. When the body exceeds the wound healing response, keloids or hypertrophic scars may form, which represent an excess of scar tissue formation.
Will they ever fade alone?
When the problem is discoloration and the "scar" is flush with the skin and there are no irregularities on the surface, they resolve themselves over time and avoid the sun. For acne scars that do not rinse with the skin, they usually do not fade on their own. The collagen in the skin needs to be remodeled or stimulated to correct these structural deformities in the skin.
Acne discoloration is called post-inflammatory erythema if it is red and post-inflammatory hyperpigmentation is darker than normal skin tone. This discoloration of the skin that is flush with the skin is caused by inflammatory cells that attack the overgrowth of bacteria, oil and dead skin that clogs the pore. Even after the acne has resolved, this pigment change remains although it will fade over time. Sun protection and avoidance are important to help this pigment change fade more quickly. If the areas of post-inflammatory erythema or hyperpigmentation are exposed to the sun, they persist for longer. A sunscreen with SPF 30 or higher, broad spectrum and ideally mineral is recommended. Newer formulations such as EltaMD and CCMD sunscreens (my brand-name sunscreen) contain zinc and titanium nanoparticles that rub instead of leaving a white film.
Additional topical treatments can be used to accelerate the improvement of these areas of discoloration. This includes the main topical treatment for acne: retinoids. Creams such as tretinoin and tazorac accelerate skin cell turnover and stimulate collagen. Retinoid creams also have a role in remodeling the scars and not only in the pigment. A recent split study (which treats a side with microneedles at home and one side with Tazorac) showed an improvement with Tazorac only in acne scars.
Can acne scars be removed permanently?
In short, yes. Depending on the type of acne scar, different modalities can be used, but in general, I have discovered that laser treatments are the most effective option for most acne scars. The two best laser devices on the market for acne scars are Fraxel 1550 and PicoWay Resolve. PicoWay Resolve is safe on all skin types, as it does not heat or break the surface level of the skin. Fraxel 1550 supplies heat to the upper layers of the skin, which may be beneficial for stimulating collagen, but increases the risk of hyperpigmentation (dark areas of the skin) in darker skin types. This risk can be mitigated with tretinoin and hydroquinone before and after treatment, but which laser is most appropriate for your skin type should be evaluated before treatment by a certified dermatologist or plastic surgeon.
Why are laser treatments the most effective treatment for acne scars? They produce the greatest amount of neocollagensis (stimulation of new collagen and elastin, which is required to reshape acne scars). One of the only ways to stimulate collagen is to damage the skin to cause a wound healing response. Lasers use light energy to create these small wounds. That said, not all lasers are creating equal or powerful enough to hurt the skin properly.
Deciding between Fraxel 1550 and PicoWay Resolve if both are appropriate for your skin type can be reduced to lifestyle. PicoWay has minimal or no downtime, but requires more sessions. For patients without five days to be red and scaly (which is the result of Fraxel), PicoWay may be the most appropriate option. For patients with an upcoming special event or those who want results as soon as possible, Fraxel 1550 would be a better option.
When Fraxel 1550 is combined with PRP (platelet rich plasma), the downtime can be reduced by one or two days and more collagen can be stimulated. The PRP uses the patient's own blood to stimulate collagen and reshape acne scars. My favorite PRP system is the Eclipse system. It is important to use a blood collection tube that contains the appropriate components necessary to activate platelets in the blood to release growth factors, signals that tell your body to heal and produce more collagen.
Other modalities that can be used in combination with laser treatments include surgical removal of acne scars, subcision (breaking the scar tissue with a needle under the scar), microneedles and TCA cross (a strong solution is placed of chemical peel within the depressed scar). to cause it to be filled with new tissue). Fillers can also be injected into acne scars, but they are often temporary and require repeated treatment.
In your experience, what is the best way to eliminate them? How long does it take?
Depending on the type of scar, the different modalities are the most appropriate. For the vast majority of scars, I start with a series of laser treatments. Usually, a series of four-six Fraxel 1550 or six-twelve PicoWay Resolve, depending on the type of skin and the patient's lifestyle. If some subsets of the scars remain after some laser treatments, the combination of crossed TCA, puncture or subcision can be used in combination with the remaining laser treatments on a case-by-case basis.
Fraxel 1550 requires numbness with topical anesthesia for one to two hours before treatment. The anesthetic cream is removed and the Fraxel 1550 treatment takes between 10 and 15 minutes for a full face. Afterwards, your face feels warm and a refreshing mask is applied for 15 minutes. An hour after treatment, the skin temperature returns to normal, but remains red in appearance. The next three and five days the skin remains red and begins to climb on day three and four, and begins to return to normal on day five and can easily be covered with makeup.
For PicoWay Resolve, no numbness is required and the treatment for a full face lasts 15 minutes. After treatment, small broken capillaries can be produced, which resolve within one or two days and can easily be covered with makeup. Some patients experience mild itching on day one or two after treatment. The redness after treatment is subtle and seems a mild allergic reaction in some patients.
What else should people know about these treatments?
Not all lasers are the same. You need the correct temperature, the correct firing speed and the correct depth and spacing of the energy laser beams. Not all treatment providers are created equal. An expert knows what adjustments will give you maximum performance without increasing your risk of hyperpigmentation, scarring or infection. While medications may have the same device or claim that your device has similar efficacy, this is not the case. Many years are dedicated to understanding and training in laser devices. You will get more for your money with a board certified dermatologist or plastic surgeon who uses a proven and true laser device with the right settings.
Microneedling has been very popular recently for acne scars. In my opinion, the result is proving to be temporary since much of the improvement is due to soft tissue swelling that masks the scar's appearance for a short time. Lasers have a longer trajectory in the treatment of acne scars, particularly Fraxel, which has historically proven to be the gold standard. PicoWay Resolve is an exciting new technology that shows excellent results with minimal or no downtime, which in our accelerated and high demand world is really amazing for us, the professionals we work for.
How can you prevent future acne scars?
Before treating any patient for acne scars, I make sure that my patients invest in a good skin care routine that treats and prevents future acne. Often, this includes one of the two best ingredients to treat and prevent the formation of new acne: retinoids and benzoyl peroxide. Retinoids fight all the components of acne formation: they remove the top layer of dead skin cells that clog pores. They also reduce oil production, which creates a good environment for the overgrowth of the bacteria that cause acne. Retinoids also help kill the bacteria that cause acne and serve as an anti-inflammatory agent.
Similarly, benzoyl peroxide works to fight acne by killing the bacteria that cause acne and removing dead skin cells from the pore (keratolytic). In more severe cases of acne where scarring is a major problem, isotretinoin is the first line treatment. Isotretinoin permanently shrinks the sebaceous gland, eliminating oil production that provides a good environment for acne that causes the overgrowth of bacteria. Historically, caution was taken not to treat acne scars while patients were taking isotretinoin, given the concern about wound healing, but this has recently been denied by more recent studies. At that time, patients had to wait to treat acne scars for six months after completing their isotretinoin cycle. Many progress has been made.
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