Smoothing the Surface
Acne scars remain one of the most challenging skin conditions to treat. The lack of a gold standard treatment to banish these permanent reminders of acne past has led physicians and product manufacturers to try new technologies, techniques and products in hopes of finding a magic bullet. While a cure remains elusive, new modalities are showing promise while offering a less traumatic path for patients seeking to reduce the appearance of their scars. “When I first started working with acne scarring, we were committed to dermabrasion, which now seems bloody and grotesque in the way it heals, and which often left people with whitened skin,” says Deborah S. Sarnoff MD, director of dermatologic surgery at Cosmetique Dermatology, Laser & Plastic Surgery LLP, in Manhattan, and clinical professor of dermatology at the New York University’s Langone Medical Center. “That was the tradeoff. But that’s not true today.”
As with antiaging treatments, acne scars that jump out at the physician aren’t always a primary concern for the patient. Accordingly, the first step in acne scar treatment is the patient consult. “Sometimes a patient is more bothered by one type of scar or by scars in a particular location. So we go back and forth with the patient to determine what’s most important, what his schedule looks like, and what his budget is for the procedure or procedures,” says Kevin C. Smith MD, FRCPC, a dermatologist with a trans-border practice in Niagara Falls, New York, and Ontario, Canada. “Tailoring treatment to a patient’s preferences is how we determine what to do—and at what rate.”
Rolling scars are the most common type of acne scarring but, because they’re often the least noticeable, they generally get the least attention from physicians. “We do the most for icepick and boxcar scarring,” notes Daniel I. Wasserman MD, head of Riverchase Dermatology & Cosmetic Surgery, based in Naples, Florida. “That’s because those scars, those deep depressions that you can’t stretch or mold or move, are less hidden with makeup.”
Second to aesthetic concerns are the patient’s reasons for seeking treatment. “It’s important to take a social history during consultation,” says Dr. Smith. “This includes talking about what kind of work the patient does and whether she has any big events coming up.” If the patient’s sister is getting married in two weeks, for example, you may want to use fillers, but not a fractional ablative laser. If the wedding is in six months, “you can do just about whatever you want without risk of appearance problems on the big day,” says Dr. Smith.
If the patient is a man who must regularly make presentations to clients, vacations may be the ideal time for treating acne scars. “If a male patient commits to fractional ablative laser treatment, he has to be willing to not shave for a while,” says Dr. Sarnoff. “Women can use cosmetics to cover the pinkness, but for men it’s harder to have that down time.”
Age and skin type also play an important role in determining the most effective treatment modailities. “As you get older, the skin envelope is looser,” says Dr. Sarnoff, “and gravity comes into play. Often, patients are more bothered as they get older because the scarring appears worse.” In some cases, she improves the overall appearance of the scars by removing some of the skin from the sides of the face, “it’s like a skin reduction facelift,” Dr. Sarnoff says. “It tightens the overall skin envelope.” She also uses a more controversial method of filling deep scars with ‘microdroplets’ of silicone used off-label.
Older skin—whether the result of instrinsic or extrinsic aging—has less plasticity and responds less favorably to acne scar treatments than younger, more pliable skin. “Because [the skin] has less plasticity, it may not heal as well or rebound as well after a procedure,” says Dr. Wasserman.
Darker skin types, “push me more to non-heat-driven procedures, because these patients have a higher risk of post-inflammatory hyperpigmentation,” adds Dr. Wasserman.
“People of color often cannot take aggressive treatments,” agrees Dr. Sarnoff. “The physician has to worry about doing something that will change the color of the patient’s skin. If you improve the contour but upset the pigmentation, you haven’t done a good job.”
Ethnic skin is more at risk for pigmentary alteration following CO2 laser resurfacing, “but turning down the energy can affect the amount of improvement,” says Dr. Wasserman. Radiofrequency-based devices “are more colorblind,” he adds, “and may actually be better for acne scarring than a laser.” Dr. Smith recommends treating darker skin during winter months, when patients have less exposure to ultraviolet light.
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