Almost everyone develops acne at some point in their lives, but for some, they’re left with unsightly acne scars that can severely impact their self-confidence. For years, there’s been an ongoing debate on the best form of acne scar treatments — some swear by surgical intervention, while others see lasers as their saving grace.
Patients often come to me using examples of individuals who’ve successfully undergone acne scar treatments, but the truth is, there’s no one size fit all solution as everyone is different. The best type of acne scar treatment depends on factors like the patient’s skin type, type of acne, skin cells and need for collagen production.
Before I explain my approach on prescribing acne scar treatments, we first have to understand that not all acne scars are created equal.
When acne breakouts form, excessive inflammation damages tissue and skin. In order to repair this damage, our body produces collagen — a substance that supports the skin. However, excess or too little collagen production results in abnormal healing and thereby permanent elevation or depression on the skin. Generally, if the body produces too little collagen, depressed acne scars form; if the body produces too much collagen, raised acne scars form.
These consist of fractional ablative lasers (e.g. CO2 1060nm) that lead to vaporization of skin and fractional non-ablative lasers (e.g. Erbium Glass 1550nm) that leave the skin’s surface intact. While Fractional CO2 Lasers have greater efficacy compared to fractional non-ablative lasers like the Erbium Glass, it carries a longer recovery time and a higher risk of complications such as post-inflammatory hyperpigmentation. This is because the Fractional CO2 laser pokes microscopic holes in the surface of the skin and stimulates collagen production to improve texture and appearance.
I usually recommend fractional ablative lasers on acne scars with surface irregularities like boxcar scars and icepick scars and fractional non-ablative lasers for acne scars the require deep tissue stimulation, such as rolling scars.
The fractional picosecond laser is a non-ablative laser that targets acne scars with more precision and safety. At my clinic, I use the Discovery Pico Plus, a second-generation triple wavelength picosecond laser that generates the highest peak power in the world. What this means is numerous micro-beams are focused 2mm under the skin, producing laser-induced optical breakdown that helps stimulate collagen production and scar remodelling.
I would say the pico laser is beneficial for both shallow and moderately deep acne scars and it’s been proven by both research and patients to have the least damage and recovery time. But of course, the patient’s suitability always has to be assessed. As the fractional picosecond laser relies on melanin absorption to generate its effect, I tend to recommend more for darker skin tones.
Most machine-based treatments are unable to reach deep into the skin. Radiofrequency micro-needling treatment overcomes this by using insulated microneedles to penetrate as deep as 4mm in the skin. As such, fractional RF micro-needling is ideal for atrophic, rolling, mixed and tethered acne scars. However, it is very technique dependent and time-consuming to treat the scars to an adequate intensity. Many doctors end up undertreating by doing only a few passes, while patients may not be able tolerate the discomfort and downtime. For successful acne scar removal, treatment parameters and intensity need to be tailored to the individual patient's scarring and circumstances.
I like to use a specialised technique called TCA Cross to treat deep acne scars. This procedure involves using a needle or toothpick to place TCA solution into deep acne scars. What TCA does is to destroy the base of the pick scar and stimulate collagen production, which levels out the acne scars. This is a tedious and time-consuming process, but the results are well worth it — one session can improve your scars by up to 30-40%.
Some acne scars are depressed due to fibrous scar tissue that fails to regenerate evenly and thus pulls the surface of the skin down. In such situations, all the chemical peels and lasers will have limited effect. With subcision, small needle punctures are used to release tethered skin scars stuck to the deeper fascia. Following which, fillers containing hyaluronic acid are injected to encourage proper repair of skin and prevent the scar from sinking back down.
I would usually recommend this combination for patients with rolling, ice pick and boxcar acne scars.
Absolutely. In fact I believe a combination approach is essential for acne scar removal treatments, especially if you have a mix of acne scars in one area. Lasers when complemented with other treatment methods can be extremely effective.
Depending on the method used and number of treatments completed, acne scar removal results can be permanent. However, results will be affected by the natural ageing process and if patients fail to ensure proper aftercare. Maintenance treatments also determine the longevity of results.
As such, I always urge patients to avoid getting complacent and to continue practising good skincare habits, like applying sunblock and moisturiser frequently. This is especially important post-laser treatment!