There are no firm medical protocols to follow in the treatment of acne scars, as it is a pathology that can be addressed with numerous therapeutic options and that are also subject to the personal and social preferences of the patient.
However, it is known that certain treatments have a more favorable risk/benefit/cost ratio for the patient who wishes to treat acne marks. Below is an expert agreement from 2016 to focus on the treatment of acne scars (Zaleski-Larsen et al.)
To evaluate it, we need to know the terminology of the different types of acne marks that exist. You can find more information by clicking here.
Alterations in skin color due to acne
What is the best treatment for red marks resulting from acne?
Erythematous macules (red spots) that remain after recent inflammatory acne usually have a good prognosis and usually disappear on their own over the course of months. However, when they require treatment by the patient, it is recommended to use vascular lasers (pulsed dye, KTP or pulsed light) together with non-ablative fractional laser in the same session.
What is the best treatment for dark marks caused by acne?
Post-inflammatory hyperpigmentation caused by acne is common in patients with dark skin (phototypes III or higher). They are usually treated as if they were sun spots or tattoos, with pulsed light or with alexandrite lasers or very short-pulse Nd:YAG (Q-switched).
What is the best treatment for light spots left by acne?
Residual hypopigmentation is not common after inflammatory acne lesions. It is recommended to treat them topically with bimatoprost 0.03% and tretinoin 0.25%. Some authors use these drugs and pimecrolimus after a session of non-ablative fractional laser to improve penetration.
Alterations in skin texture due to acne
What is the best treatment for wavy or rolling acne scars?
Rolling scars are those that look like desert dunes. Their main characteristic is that underneath them there is fibrous tissue that anchors them deep to the skin. For this reason, it is essential to treat this underlying fibrosis initially using the subcision technique. Otherwise, the following therapeutic steps will be less effective. Subcision is a process with an excellent risk/cost/benefit ratio.
What is the best treatment for boxcar scars?
Box scars are round or rectangular depressions, with well-defined edges and a size of between 1.5 and 4 mm. A punch excision is recommended whenever they are deep or wider than 3 mm in diameter. Superficial van scars usually respond to fractional CO2 laser and/or non-ablative fractional laser.
What is the best treatment for icepick acne scars?
Given that ice pick scars are deep and less than 2 mm in diameter, it is recommended to excise them with punch or to destroy them by fractional or pure CO2 laser, the first option being preferred by most authors.
What is the best treatment for hypertrophic acne scars and their keloids?
Although in atrophic acne scars (whether in a van, wavy or ice pick) there is a certain agreement of therapeutic action, in hypertrophic scars and keloids this is not the case once the first step in treatment has passed . Here is a guide on the different therapeutic options available.
It seems that the therapy with the best risk/benefit/cost ratio for the treatment of hypertrophic scars and keloids is cryotherapy plus intralesional infiltration of corticosteroids and/or 5-fluorouracil. However, it is common that, depending on the stage of the lesions, different types of lasers can be added in combination.
CONCLUSIONS
- Acne scars usually do NOT disappear with treatment, although they can improve dramatically.
- Usually the patient has different types of scars simultaneously, so the normal procedure is to COMBINE different treatments throughout the therapy, either in the same session or in separate sessions.
- The improvement in acne scars is PROGRESSIVE and it is possible that in the first weeks or months even an initial worsening is noticeable. The necessary destruction of scar tissue for new collagen to be manufactured can result in a temporary initial worsening. This is especially common in boxcar and icepick scars treated with CO2 laser.
REFERENCES
· Zaleski-Larsen LA, Fabi SG, McGraw T, Taylor M. Acne Scar Treatment: A Multimodality Approach Tailored to Scar Type. Dermatol Surg. 2016 May; 42 Suppl 2:S139-49.