A. Deep acne scars take on different appearances and are categorized:
Atrophic: shallow and heal underneath the top layer of the skin leaving a depression in the skin with collapsed and condensed collagen. The sub classifications of those are as follows:
- Ice Pick Scars – deep, narrow, pitted scars that look like holes
- Rolling Scars – sloping edges making the skin look wavy and uneven
- Boxcar Scars – larger than ice pick scars with sharp defined edges, looks like craters Atrophic superficial – ivory, flat, tiny wrinkle appearance (like a 1-2mm stretch mark).
Hypertrophic and Keloid: Scars are raised versions of the healed skin with white, pink, or dusky coloration. They are thick and wide with a waxy feel on the surface. High risk areas include jawline, back of the neck, center chest, shoulders. Hypertrophic scars stabilize at the site of the original pimple remaining slightly raised and can be tender or itchy. Keloid scars begin to spread with newly made bundles of tightly wound collagen beyond the origins and can be tender or itchy. Both have an overproduction of collagen, the mechanism and triggers not known. The gold standard of treatment remains Kenalog (steroid) injections to break down excess collagen, producing softer, flatter, less symptomatic scars. Injections are generally done by medical health care provided in series over time.
Post-Inflammatory Hyperpigmentation: Known in short form as PIH, this is not a scar per say but is a discolored spot or area that is the result of the acne itself or from squeezing and picking. The healing process blurs the top layer from the underlying layer of the skin, and pigmentation becomes trapped among collagen fibers. Older blood vessels remain at the site of healing giving a darker appearance.
Don’t Forget! Your dermatologist also trained as a Dermatosurgeon! One of the only medical specialities to require this for royal college board certification!!
Dr. Fisher and Dr. Poulos and the dermatologists at Kingsway Dermatology & Cosmetic Centre have combined 20-25 years each providing both medical, surgical and cosmetic care for acne and acne scarring. Wow! Now that’s expert service.
A combination of treatments is often required because patients have more than one type of scars. Many treatments can help in several types of scarring too! PIH can be improved with laser genesis, chemical peels, and micro needling. Ice-pick and boxcar scars can be improved with fractionated ablative laser, microneedling, subcision, and filler injections.
An initial stage of treatment may include:
TCA Cross: This is droplets of trichloroacetic acid applied in a high concentration directly into the appropriate scars to cause an inflammatory reaction leading to new collagen formation to fill the deep pit
The purpose s to improve the look by filling in the scar therefore reducing reflection and shadows, minimizing the look of the scar and providing the appearance of smooth skin.
Once the area of scar treatment has been degreased a small toothpick is saturated in the acid then applied into the scar. The scar will immediately frost over in white and you will have to leave the clinic with these. It’s best to keep the treated areas slightly moist using an occlusive barrier such as Vaseline or Aquaphor. In the days ahead they will scab and repair as a typical wound would. It’s common for scars to be treated 2-5 times with TCA Cross over a period of 6-8 weeks apart for desired result. This is not a rapid results treatment so patients must manage their expectations with a range of 6 months to a year.
Punch Excision: This technique for the revision of acne scars is reserved for isolated ice pick and very small boxcar scars. It’s performed with a tool used for punch biopsies and is like a hole punch for your skin. It’s able to excise firm, trapped, scar tissue, and the level edges are sutured to close it up and heal leaving a small even hairline scar.
Both TCA Cross and Punch excisions need to be followed up with another treatment modality. They’re considered Stage 1 treatments and must be followed with a Stage 2 treatment such as laser resurfacing and microneedling.
Subcision: Subcutaneous incisional surgery is a perfect treatment for rolling scars. It works by use of a hypodermic instrument such as a cannula or needle that is inserted by way of a small puncture and used to break fibrotic bands that are tethered to the tissue underneath. By untethering these fibrotic bands you are creating space which will allow for new collagen structures and formation by the process of wound healing. This treatment works exceptionally well with the placement of hyaluronic acid fillers underneath where the scar was tethered, to act as a support bridge while new collagen forms.
Fractional Laser Resurfacing: This laser resurfacing treatment works by creating microscopic pixelated punctures which represent injury zone (1/100mm and smaller). These are created with an energy source leaving the surrounding skin intact or so-called skip zones. The laser can be set to deliver 10%-50% fractionated wound columns. One can expect up to 20% improvement per treatment with a minimum of 4-6 treatments or more for atrophic (indented or pitted) scars.
Creating this dermal injury allow the benefits of wound healing to occur in the various layers of the skin. An immediate improvement can be seen once the epidermal layer from the microscopic scabs shed. The injury in the deeper dermal areas work to rebuild new collagen over time for long term benefits. The greater the density/ or percentage coverage of thermal injury zones per treatment the greater the immediate swelling, redness and healing. So the healing downtime can be individualized (generally)
The treatment helps to remove PIH and smooth surface scars. With precautions it can be used on all skin types.
Full Field Laser Resurfacing: Treats the entire face by removing a top layer. A laser beam scans the treatment zone and with precision and removes the layer. This treatment can only be performed on fair skin types and there is downtime associated with it that is 2-3 weeks and erythema that can last for a number of months. However, for the right candidate with severe, deep textural scarring it is worth it to create new smooth skin.
IPL/ BBL/ Laser Genesis
Photorejuvenation: We have various light and laser therapies that can be used on a range of skin types to assist with lifting stubborn PIH and residual redness. These are the least invasive of the laser and light therapies with little down time but are only attracted to the pigmentation and will not assist with other types of acne scars.
Depigmentation skin care which will assist with removing PIH or act as a pre or post treatment for laser resurfacing treatments. Z.O. medical skin care and Universkin boutique ingredients provide unique lightening opportunities that are well tolerated, non invasive, and easy to price.