Acne scarring Dr Paul Charlson President British College of Aesthetic Medicine GPwER in Dermatology and Medical Director Skinqure and Intoskin Clinics Welton Leeds Chelsea and Canary Wharf

Myth – acne scaring is just “cosmetic” “I have not looked in the mirror in years, and is painful not to be able to do that, and that is a direct result of acne, the acne scarring.” “I think that if I had more self-esteem about the way I looked, I think I would have been more outgoing. I would have gone to more parties” “Our study showed that post-acne scars have a significant negative effect on the QOL of young adults. It highlights the need to increase public awareness of acne vulgaris and its sequelae through education programs and advocating early treatment to reduce the risk of scarring.” J Cutan Aesthet Surg. 2015 Jul-Sep; 8(3): 153–158. The Impact of Post-Acne Scars on the Quality of Life Among Young Adults in Singapore

Myth – Acne scaring is not treatable or preventable Treatment can have good results – up to 75% reporting good to excellent Even a “medical failure” might please the patient Early treatment will reduce incidence of scarring Picking spots may increase scarring

Who gets acne scarring? Nearly all patients get some degree of scarring Men are more likely to get truncal scarring and this can often be hypertrophic or keloid There is a correlation between severity of acne and degree of subsequent scarring Scarring is explainable by the depth and severity of the inflammation within the active acne lesion and individuals ability to heal There is a lag time of up to 3 years from comedone to scar

HISTORY Which aspects of the patient's scarring are the most bothersome to him/her? How distressed is the patient about his or her scars? What are the patient's goals for treatment? Have any prior procedures been performed to treat the scars? Has the active acne cleared completely? How recently did the acne clear? Was isotretinoin used? How recently was it discontinued? Is there a history of postinflammatory hyperpigmentation (PIH)? Is there a history of keloids or hypertrophic scars? PHYSICAL EXAMINATION Direct overhead lighting is optimal Have a mirror for the patient to point out lesions Evaluate for active acne Define types of scars (icepick, rolling, boxcar, severely atrophic/sclerotic) Assess color (hypopigmentation, hyperpigmentation, purple/red discoloration) Assess depth of the lesions Stretch skin to see if scars disappear Palpate for underlying fibrosis Evaluate skin type (types III–V have increased risk of PIH with most procedures)

Goodmans 4 point acne scarring scale GRADE 1: MACULAR • Erythematous, hyper-, or hypopigmented marks GRADE 2: MILD DISEASE • Mild atrophy, can be covered with makeup or facial hair GRADE 3: MODERATE DISEASE • Moderate scarring, not covered by makeup but can be flattened by manual stretching of the skin GRADE 4: SEVERE DISEASE • Scarring not flattened with manual stretching of the skin

Types of acne scar 1. Macular marks – not true scars PIE post inflammatory erythema 2. Atrophic scars- rolled, ice pick, boxcar, atophic macules 3. Raised – hypertrophic or keloid scars 4. Other pigmentary issues – hypopigmentation, persistent post inflammatory hyperpigmentation.

Pigmented Marks PIE – post inflammatory erythema-blanches on pressure PIH – post inflammatory hyperpigmentation

Treatment of PIE marks They fade over six months Regular sun protection Vascular laser

Treatment of PIH Inhibit tyrosinase – reduce melanin production Increase cell turnover – spots fade faster Block the sun Arbutinin, Hydroquinone,azeliac acid kojic acid, liquorice root extract – all inhibit tyrosinase Tranxemic acid and Niacinamide also prevent melanin production AHA , retinoids- increase cell turnover

Main types of Atrophic Acne Scar

Rolling Scars Gently slopping sides rolled edges Fibrous bands of tissue develop between the skin and the subcutaneous tissue below. These bands pull the epidermis, binding it to deeper structures of the skin.

Depressed fibrotic boxcar scars Steep sides often larger, firm to touch. Inflammatory breakout destroys collagen, tissue is lost. The skin over this area is left without support, and a depressed area is created. Boxcar scars may be superficial to severe, depending on the amount of tissue lost

Treatment Planning Treatments are often long term and combination Expectations and goals- psychological assessement Financial considerations Time constraints Downtime Non ablative laser or micro-needling better than fractional ablative Excision likely to heal quicker than subcision or ablative resurfacing

Subcision 18 G Nokor needle Topical / local anaesthetic Inserted bevel upwards into deep dermis and then back and forth and fan like motion. Only allow a small haematoma to form Ice and pressure Bruising and swelling are significant

Dermaroller / Dermal Pen Percutaneous collagen induction Safe and minimal downtime Takes six months and sometimes several treatments required 75% show good or excellent result Best with shallow to medium depth scars

Dermaroller treatment

Dermaroller

Laser Lasers are usually fractional where there are islands of untreated skin as this reduces downtime. Ablative lasers affect the surface of the skin whilst non ablative work have less epidermal effect reducing downtime but are less effective in a single treatment Good improvement and can treat a range of scars Deeper scars better treated with more ablative laser Downtime up to 2 weeks depends on type Expensive and cannot use in type 5 and 6 skin

CROSS TCA Chemical reconstruction of scars 70-100% TCA for 10 seconds or when frosting occurs- wash off with saline Often need to repeat up to 5 times Care in pigmented skin as hyperpigmentation can occur

Cross TCA

Dermal fillers Soft scars are filled with a Hyaluronic acid filler Tether scars are subcised using a Nokor needle first. It bruises – Then filled – 90% are improved

Surgery Good for isolated ice pick scars Use a punch biopsy and suture or glue Punch elevation In larger ones graft a small area of skin Good result

Icepick Scars Small jagged scars – steep sides Develop after an infection from a cyst or other deep inflamedblemish works its way to the surface. Skin tissue is destroyed, leaving a long column-like scar.

Treatment of rolling scars Subcision Dermal filler after subcision Microneedling Fractional laser – ablative or non ablative

Treatment of Boxcar scars Cross TCA – small lesions Punch excision for small deep scars Punch elevation –moderate medium sized scars Punch grafting – deep scars Ellipse incision Skin needling Fractional laser – choice of ablative laser or non ablative

Treatment of Ice Pick Scars Cross TCA Punch Excision

Keloid acne scars Difficult to treat Often recur after treatment Can use pulsed dye laser Inject with steriod + or - cyrotherapy

Keliod after pulsed dye laser