What Is It?
Scars form in response to injury to the skin for a number of reasons:
After skin inflammation such as acne or a viral infection of the skin (chickenpox)
Scar formation is a natural part of the skin’s healing process whereby the body tries to repair damage, producing fibrous tissue called a scar. Scars are composed of collagen, the same material present in healthy skin, but in scars these fibres usually align in one direction rather than the random basket-weave pattern that gives normal skin its suppleness and strength. As well, scar tissue also does not re-grow sweat glands and hair follicles. They are often depressed, elevated, pink, red or shiny and can cause itching, tenderness, pain and a decreased range of motion.
What is my Risk of Developing Scars?
Several factors influence how your skin scars. Some individuals are at a higher risk of developing scars, including those with severe acne, coloured skin, a family history of scars, a history of keloid scarring or individuals where a surgical procedure has been operated in a high risk area, such as the chest and upper arms. Most scars may improve over time. They never disappear completely and can be aesthetically disfiguring and unappealing. Having a specialist dermatologist identifying your scar will result in treating the scar appropriately and providing proper counselling. Specialist dermatologic surgeons take special precautions when treating people who are more prone to scarring, to deliver the best aesthetic result as well as a medical outcome. At the Skin Specialist Centre, our specialist dermatologists are expert in treating all scar types.
Acne Scars: Scars that remain after acne treatment can be either depressed or raised. These present in three main types – boxcar, icepick, rolling and combinations of the three. Rolling scars are those which are like broad, low hills. Boxcar scars have a thick, hard centre which is often white, that pulls down in the centre. Icepick scars are very narrow and deep. These are all depressed (atrophic) scars, meaning there is an overall loss of skin. Most acne scar treatments attempt to either remove or replace abnormal tissue and to stimulate new collagen formation to fill in the old scars. Raised acne scars can be either hypertrophic scars or keloids (see acne scars).
Hypertrophic and Keloid Scars: Two common types of scarring seen in the skin are hypertrophic and keloid scarring, both of which are caused by excess collagen growth during the healing process, resulting in a firm, raised, purplish/red scar. Hypertrophic scars result in a raised scar compared to the surrounding skin. Keloid scars are hypertrophic scars which grow larger and outside the original wound area, and can occur in anyone but most commonly in dark-skinned people. There are certain factors that increase the likelihood of hypertrophic and keloid scars which include age, location of trauma, nature of the injury, patient race and surgical technique, all of which play a role in the development of hypertrophic and keloid scarring. Such scars are more common in young adults and are more likely to occur on scars on the chest, shoulders, back and jawline areas. Hypertrophic/keloid scars are more common in Asians and dark skin types and are also more common in acne patients, burn injuries and surgical excisions.
Hypertrophic and keloid scars are more common if poor surgical technique is initially performed. To reduce the incidence of these scars it is essential that wounds be orientated correctly at the time of surgical removal of a lesion, that tension is reduced and special non-reactive sutures are placed within the wound.
Keloids can be caused by acne, body piercings, surgery, tattoos or any injury or inflammation of the skin. Keloids are much more common on the chest, shoulders, upper back, arms and ear lobes and also tend to itch and be painful. A combination of treatments produce the overall best result, including silicone sheeting applied to the scar, injections of intralesional steroid/Five Fluorouracil, pulse dye laser treatments (Candela VBeam Perfecta) and fractionated CO2 (Smart Xide Dot laser).
Acne marks and scars
Brown marks or red marks persisting on the skin where acne has occurred and where the acne has now cleared is a most common complaint amongst acne patients. Many patients feel these red or brown marks make their skin appear more broken-out and uneven than it truly is. Treatments are available to help lighten and remove these old acne marks. The Genesis procedure is a gentle, painless and no down-time laser treatment which can speed up the process of reducing the red and brown marks.
Choosing a specialist dermatological facility for acne scar removal provides more choices for treatments, ways to control future outbreaks and complementary cosmetic procedures to restore your skin’s appearance. Acne usually leaves some scarring, although it is often minimal and most people experience acne outbreaks in the course of their lives. Acne is most common during adolescence, but acne can occur at any time and adult acne often erupts more severely, producing disfiguring scars. As the acne lesions heal, the various shapes and sizes of scars remain as a permanent reminder of this common facial eruption.
Acne scars make many people feel embarrassed or self-conscious. Fortunately, acne scar treatment can remove or minimize them through cosmetic treatments. Treatment options depend on the severity of the scarring and the type of acne scar.
What are Acne Scars?
Permanent textural changes and indentations that occur on the skin following severe acne result in acne scars. Scarring occurs as the body creates collagen to repair the damage. Depending on the skin type and other factors, the scarring can be relatively shallow and easy to correct, or deep where scarring is more severe. The healing process creates significant changes in the texture and smoothness of the skin, forming depressions (lost tissue) or giving the skin a rolling, wave-like appearance (adds tissue).
Why Does Acne Scar?
Acne is an inflammatory process. In the non-inflammatory phase (when there are only comedones), there is no scarring. Once the non-inflammatory lesion evolves into an inflammatory lesion, the mechanisms of wound healing are activated. If the inflammation is extensive and deep extending into the deep dermis and continues untreated, scarring results. The different types of acne scars are as a result of the extent, depth and degree of inflammation that is followed by repair. On the face, commonly there is an indentation (depressed scar), and on the chest and the back the scarring can be raised and lumpy – known ashypertrophic or keloid scarring.
What Does Acne Scarring Look Like?
On the face, acne scarring appears as damage to the skin texture with indented areas of various sizes. On the chest and back, scars tend to be raised and lumpy. The following are the main types of acne scars:-
Boxcar acne scars:
Boxcar scars are punched-out scars with vertical, sharp edges which may be shallow or deep. They are most commonly located on the cheeks and temples. Shallow scars are treated with subcision, followed by either full laser resurfacing (ablative CO2 – Smart Xide Dot laser), fractional lasers (ablative CO2 or ablative Erbium – Smart Xide Dot laser, Fraxel Restore Dual), dermal fillers and radio-frequency treatments (e-Two Sublative). Deep scars can be treated with punch excision, followed by resurfacing (to remove the surface layer of the skin and promote new skin cell production).
Icepick scars are deep, narrow, sharply defined tracts, extending vertically to the deep dermis or the subcutaneous tissue, creating an appearance that the skin has been punctured with an icepick. The surface opening is wider than the deeper portion as it tapers into a vee and gives the appearance of open pores and tend to worsen with age, as the skin becomes lax. They are more commonly seen on the cheeks, between the eyebrows and the nose. Due to the depth of ice-pick scars, fractional treatments are not as effective as TCA cross (i.e. trichloroacetic acid chemical reconstruction of skin scars). Punch excision and laser resurfacing are supplementary procedures to enhance results.
Rolling scars appear as undulations and depressions on the skin (create a wave-like pattern). They are shallow, atrophic scars that are caused by tethering of the underlying dermis to the subcutaneous tissue by fibrous bands. They are wide scars, with relatively normal appearing skin. The clue to these types of scars is that these scars will get effaced and appear normal if the skin is stretched. Among the various types of acne scars, they are relatively easier to treat. Methods of treatment include subcision, fractional laser resurfacing (Fraxel Restore Dual), radio-frequency (e-Two Sublative) and dermal fillers (hyaluronic acid). Acne scarring of this sort usually requires several treatments for the best possible outcome.
Mixed Acne Scars:
The most common form of acne scarring is a mixture of the above, hence numerous treatment modalities will be required for improvement and a tailored approach to scar revision is necessary to provide the best outcome.
Red Acne Scars – Macular Scars:
Flat erythematous acne scars are commonly seen on the cheeks and forehead areas and occur as a result of early acne scarring. Generally this type of scarring can fade over 6 – 12 months without treatment. Vascular laser treatment (Candela VBeam Perfecta laser and Excel V) will hasten the resolution of scars and several treatments are usually required for an optimal result.
Darker (especially those with type IV – VI) skin types have a tendency to develop pigmentation in areas of inflamed skin. It can be transient, but if it persists treatment can be considered with the Q-switched Yag laser (Revlite) or with bleaching creams such as varying concentrations of Hydroquinone.
Hypertrophic and Keloid Scars (see Scars)
How is Acne Scarring Treated?
There are numerous treatments available for acne scars which can improve and soften the appearance of scarring. Given the complexity of acne scars, a combination of treatments is required. The treatment approach will depend on four factors:
Scar type (boxcar, rolling, icepick, hypertrophic or keloid)
Time available for the procedure
Cost of the procedure
Various methods of treating acne scarring are provided by the Skin Specialist Centre:
Hyaluronic acid fillers are best suited for shallow, broad-based acne scars and have the advantage of immediate improvement and minimal downtime. Treatment is usually repeated at six monthly intervals.
Intralesional corticosteroids/Five Fluorouracil injections are best suited for thick, lumpy scars. Usually several injection treatments are needed and the treatment can be combined with vascular laser at the same time.
There are two main types of laser treatments – ablative and non-ablative. With ablative lasers there is removal of thin layers of skin, and with non-ablative lasers (non-wounding) there is stimulation of collagen growth and tightening of the underlying skin.
Ablative lasers are of two types – fractional or non-ablative and fully resurfacing. Fully ablative CO2 lasers are best used on lighter skin types, whereas fractional CO2/Erbium lasers have a much higher safety profile than fully ablative lasers and can be used on all skin types. The downside of ablative lasers is the longer recovery time which can be up to three weeks, with redness being the most common temporary side-effect. Fractional (non-ablative) lasers are of variable wavelengths and improve acne scarring, especially in atrophic and rolling scars. They are also associated with temporary redness but there is no breakage of the skin surface. They have the advantage of rapid recovery times and the ability to treat darker skin types, with a higher safety profile. Recovery time is between 5 – 10 days. Most individuals will benefit from a series of fractional treatments but five treatments are usually required.
This is a non-invasive method of scar remodelling and is best employed in early acne scars, atrophic scars, rolling scars and is ideal in treating darker skin types, having the benefit of minimal chance of post-inflammatory hyperpigmentation. The eMatrix system (e-Two Sublative) is a unique sublative treatment which delivers a fractionated bi-polar radiofrequency technology that is highly effective for improving acne scars. This treatment is safe and effective on all skin types. The radiofrequency energy delivers fractional bulk heat deep into the dermal layer, to induce a skin injury in the region of the electrode handpiece. The skin surface and the surrounding tissue are not damaged, resulting in an accelerated healing process while maximising collagen production. The sublative treatment impacts only 5% of the top layer of skin (the epidermis). Therefore most of the dermis (the deep layer of skin) is affected, giving each individual optimal results with a quicker healing response and minimal downtime.
TCA Cross (trichloroacetic acid chemical reconstruction of skin scars)
This method uses high strength trichloroacetic acid, with strengths varying between 50 – 100% and is ideal for icepick scars. Usually two to three treatments are required.
Surgical Methods of Scar Removal
Such procedures include punch excision, punch elevation and subcision, which are useful for deep icepick scars, as well as tethered scars. Usually such approaches are followed by laser resurfacing or radio-frequency.
Subcision is an excellent treatment for rolling or boxcar-type acne scars, which often have fibrous attachments holding the base of the scar down to the underlying deeper tissue. After the surrounding skin is anaesthetised, a small needle is carefully inserted under the skin to sever and release these attachments beneath the scar. During the healing process, collagen remodelling occurs and new collagen is laid down beneath the scar, further improving the smoothness of the skin. Occasionally a filler substance (hyaluronic acid) can also be injected under the scars after subcision, to make the scar look less visible and to produce further enhancement.
Acne Scarring Outcome Following Treatment:
The specialist dermatologist’s approach to treating acne scars is improvement rather than cure, with the degree of improvement being dependent on the combination of scar types and skin colour. Each person’s acne scars are a challenge for the specialist dermatologic surgeon and requires a tailor-made approach to the individual’s goals, tolerances, scar type and skin type, along with the specialist’s offering of a wide range of treatments as stated above. Understand that the deeper more extensive scars will take several treatments and patience while the skin heals. Superficial scarring will require patience as well. Management of darker skin types acne scarring can be difficult as the key problem is the avoidance of darkening of the skin (post-inflammatory hyperpigmentation). With the combination particularly of non-ablative laser procedures, radio-frequency devices and post-procedure fading creams and photo-protection acceptable results are usually achieved.
Chickenpox Scars Removal
Fortunately, chickenpox has become rare due to childhood vaccination. Unfortunately, many of us had no such vaccinations decades ago and have chickenpox scars on the face as a reminder of the childhood illness. Typically, chickenpox scars appear as round, depressed marks on the face and tend to be small and of concern when located in prominent areas. Treatment for such scars involves several options, depending on the location and type of scar. Small scars may best be simply removed by punch excision. Other treatments include bi-polar radiofrequency (eTwo Sublative) and fractionated CO2 resurfacing (CO2RE, Smart Xide Dot laser, Fraxel Restore Dual).
Hypertrophic or keloid Scars Removal
These are thick, lumpy scars most commonly seen around the back, chest, jawline and neck. Such scars are best treated with a series of corticosteroid/Five Fluorouracil injections, with the injections spaced six weeks apart and around two to four injections are usually required. The redness in the scars can be treated with state-of-the-art vascular lasers – Candela VBeam pulse dye laser, and Excel V.
Surgical Scars Removal
Scars may occur after any type of surgery and may present as thin, white lines, thick wide lines or they may be red, thickened, raised or itchy. All types of scars in the skin can be treated. Treatment options are extensive and include silicon gel sheeting, injections of intralesional steroid/Five Fluorouracil and laser treatments performed on the scar. VBeam pulse dye laser treatments (Candela VBeam and Excel V) reduce redness and help to flatten surgical scars. Fractionated CO2 (CO2RE, Smart Xide Dot laser) is also effective in flattening the appearance of scars.
What’s the next step?
If you already have an appointment booked at The Skin Specialist Centre, you can easily add a scar treatment/consultation to your booking by calling our friendly team on (09) 524 5011. If you have never been to The Skin Specialist Centre, you can either give us a call on (09) 524 5011 or make an enquiry by clicking on the Enquire Now option below.