Post-acne Scar management

Everyone wants glowing, flawless skin. But for many of us, it’s hard to have it, especially when one has dry skin, excessively oily skin, dull skin etc. In fact, in Dermatology, one of the most common skin issues encountered is Acne. 

What is Acne, exactly?

Acne is a skin condition that occurs when the hair follicles become plugged with oil and dead skin cells.¹ It causes whiteheads, blackheads or pimples, which can be embarrassing and make one feel bad about their appearance. Usually, anyone can get Acne, but it is most common in teens and young adults. ^1,2

Pathogenesis of Acne ^{2, 3}

The pathogenesis of Acne is mainly attributed to increased sebum excretion. Human skin has pores that connected to follicles and further to the sebaceous glands. The sebaceous glands make sebum that empties onto the skin surface through the opening of the follicle.

Pimples grow when these follicles get blocked, and oil builds up under the skin. Skin cells, sebum, and hair can clump together into a plug. The mixture of oil and cells allows bacteria such as Propionibacterium acnes that generally live on the skin to grow in the plugged follicles and cause inflammation, swelling, redness, and sometimes pain.

A range of factors can also trigger Acne including hormonal imbalance, androgen levels, some medications that contain androgen and lithium, greasy cosmetics, emotional stress and high glycemic load. 

Typically, Acne  can be temporary, but, it can cause scars that will last for years.

Why acne results into scarring?

Scarring is the natural part of the body’s healing process by which wounds are repaired. Scar occurs when there is significant damage to the dermis. Most wounds, except for minor ones, result in some degree of scarring.⁴ 

Acne scars frequently result into an inflamed lesion, such as a papule, pustule, or cyst.4 It has a prevalence of over 80% in adolescents and persists in 12–14% of cases into adulthood.5 Inflammation is the single major indicator of scar development. When the follicle, or pore, becomes enlarged with excess oil, dead skin cells, and bacteria, results in inflamed blemishes.

More severe lesions occur when there is a deep break in the follicle wall. The skin forms new collagen fibres to repair the damage done to the dermis. Collagen is the fibrous protein that provides the skin with its strength and flexibility.⁴ Unfortunately, the finished "repair job" never looks as smooth and flawless as before the injury.

Various types of scars resulting from Acne

Acne scars come into different forms, i.e. atrophic and hypertrophic scars depending on whether there is a net loss or gain of collagen, respectively. Atrophic or depressed scars have been sub-classified into ice pick, boxcar, and rolling scars. (Fig.2) ^{5, 6}

80-90% of people with acne scars have scars associated with a loss of collagen (atrophic scars) compared to a minority who show hypertrophic scars and keloids.⁶

Treatment for acne scars

Although acne scars cause significant concern for patients and clinicians, there is no standardised treatment protocol or indeed single modality used for all scar types. First, a comprehensive patient history is required, which should include all pharmacological acne treatments, including recent isotretinoin use and history of any keloid or hypertrophic scarring.

Several approaches have been developed, but as atrophic scars are most common on the face, these are directed towards them.

Ice pick scars: ^{7, 8, 9}

• Topical retinoid: A treatment helps in the cell regeneration, improving the skin’s texture, and reducing discolouration and make scars less noticeable. A product containing retinol can be best utilised for treating atrophic or depressed scars.
• Medium depth chemical peels: It helps in the destruction of the epidermis and part or all of the papillary dermis. TCA 35% is used as a medium-depth peel and found to be effective for ice-pick scars.
• Microdermabrasion: A more superficial variation of dermabrasion that only removes the outer layer of the epidermis accelerating the natural process of exfoliation. It is less effective for this type of scar.
• Laser ablation: Ablative laser is a wounding laser that removes the thin outer layer of skin and heats the underlying skin, i.e. dermis, which stimulates the growth of new collagen fibers. Ablative fractional lasers may be less effective for deep ice-pick scars.
• Punch excision:  It removes a pitted scar with a straight-walled disposable that is slightly larger than the scar being addressed. Punch or elliptical excision to the subcutaneous level is preferred for ice pick scars.

Rolling scars: ^{8, 9}

• Spot TCA: A TCA peel dissolves cells in the epidermis. As the skin that’s been affected by TCA application peels off, new cell growth is encouraged underneath. It is not so effective for rolling scars.
• Dermaroller: Also known as microneedling. It involves rolling a needle-studded device over the skin to stimulate underlying tissue. It's a safe, simple and possibly effective technique for rolling scars.
• Laser ablation: Ablative lasers achieve removal of the damaged scar tissue through melting, evaporation, or vaporisation. All patients with rolling scars are candidates for laser treatment.
• Subcision: It is a procedure in which a needle is inserted under the skin and moved in multiple directions to separate the top layer of skin from the scar tissue below and resulted into a healing process that forms collagen and pushes the scar up. Subcision is highly effective and commonly used for rolling acne scars.

Boxcar scars: ^{7, 8, 9, 10}

• Spot TCA: The CROSS technique is used for narrow boxcar scars. A high-strength trichloroacetic acid (60-100% TCA) peel solution is placed in the base of these scars to ablate the epithelial wall and to promote dermal remodelling.
• Dermaroller with PRP: PRP is an autologous concentration of human platelets contained in a small volume of plasma. The potential benefits have been seen with the PRP as an adjuvant to CO2 laser in the treatment of atrophic acne scars. The addition of PRP to microneedling has been delivered good results and enhanced the outcome in patients with atrophic acne scars physically and mentally.
• Laser ablation: Ablative lasers are considered a top treatment for boxcar scars. They often improve scars in just one session. They also stimulate the production of new collagen and remodelling of the scar.
• Subcision: It involves inserting needles under the skin to loosen fibers below a scar to help improve its appearance. It is a less effective treatment for boxcar scars.
• Filler: Injecting collagen or fat under the skin and into indented scars can fill out or stretch the skin. It makes the scars less noticeable. Fillers are less effective than other approaches to manage this type of scars.
• Dermabrasion: Dermabrasion is similar to microdermabrasion but goes deeper to remove the whole top layer of skin using a machine-driven or handheld device. Dermabrasion can help improve shallow boxcar scars.

Laser Treatment: ^{6, 13}

All patients with boxcar scars or rolling scars are candidates for laser treatment. Different types of laser, including the non-ablative and ablative lasers, are very useful in treating acne scars. Ablative lasers achieve removal of the damaged scar tissue through melting, evaporation, or vaporisation. Most commonly used ablative lasers for the treatment of acne scars are carbon dioxide laser and Erbium YAG laser. These abrade the surface and also help tighten the collagen fibres beneath.

Non-ablative lasers do not remove the tissue, but stimulate new collagen formation and cause tightening of the skin resulting in the scar being raised to the surface. Among the non-ablative lasers, the most commonly used are the NdYAG and Diode lasers.

The psychological impact of post-acne scars and expectations of a patient after treatment

Acne scars can be an unwanted reminder of Acne and may reduce self-esteem in some people. It can cause psychological distress and may interfere with social life or relationships. Post-acne scars impact can have dissatisfaction with appearance, embarrassment, self-consciousness and lack of self-confidence. Furthermore, it is also associated with feelings of anxiety, depression, anger, less satisfaction with the body and lower self-worth. ¹⁴

Most treatments can reduce the size and visibility of acne scars. With time, many of the treated acne scars fade, making them barely noticeable. The results of the treatment will not be visible right away. Within 2 to 4 sessions, patients may start to see how well the treatment worked to reduce the appearance of acne scars. While dermatologists offer safe and effective treatment for acne scars, there may be a better solution for timely and proper treatment. 

Reference:

1. Mohiuddin AK, A Comprehensive Review of Acne Vulgaris. J Clin Pharm 2019, 1:(1); 17-45
2. Acne, Available at https://www.niams.nih.gov/health-topics/acne/advanced#tab-overview, last accessed on 14^th September 2020
3. Acne, Available at https://www.niams.nih.gov/health-topics/acne#tab-risk, last accessed on 14^th September 2020
4. Scars and Your Skin, Available at https://www.webmd.com/skin-problems-and-treatments/scars#1, last accessed on 14^th September 2020
5. McGoldrick RB, Theodorakopoulou E, Azzopardi EA, Murison M. Lasers and ancillary treatments for scar management Part 2: Keloid, hypertrophic, pigmented and acne scars. Scars Burn Heal. 2017;3:2059513116689805.
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10. Porwal S, Chahar YS, Singh PK. A Comparative Study of Combined Dermaroller and Platelet-Rich Plasma Versus Dermaroller Alone in Acne Scars and Assessment of Quality of Life Before and After Treatment. Indian J Dermatol. 2018;63(5):403-408.
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12. How Acne Is Treated, Available at https://www.verywellhealth.com/acne-treatment-4014193, last accessed on 14^th September 2020
13. Rivera AE. Acne scarring: a review and current treatment modalities. J Am Acad Dermatol. 2008;59(4):659-676.
14. Hazarika N, Archana M. The Psychosocial Impact of Acne Vulgaris. Indian J Dermatol. 2016;61(5):515-520.