Acne scarring can be classified as icepick, boxcar, or rolling scars based on their width, depth, and architecture. Treatment options include topical agents, superficial and medium-depth peels, dermabrasion, fillers, fat transfer, needling, fractional photothermolysis, and surgical techniques like excision, grafting, and subcision. Superficial peels improve boxcar scars but may require multiple sessions. Dermabrasion is effective for acne scars but requires proper patient selection and technique. Fillers and fat transfer work best for atrophic depressed scars. Needling induces collagen without damage to induce healing. Surgical techniques are best for deep

1. ACNE SCARACNE SCAR
BYBY::
Dr.Mohammed Abd AlhusseinDr.Mohammed Abd Alhussein
LaftahLaftah
Resident of plastic andResident of plastic and
reconstructive surgeryreconstructive surgery
11

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Acne scarAcne scar
introduction
Scar is defined as ‘‘the fibrous tissue that replaces normal
tissue destroyed by injury or disease’’.
Causes of acne scar:
formation can be broadly categorized as either the result
of increased tissue formation or, more commonly, lossor damage of
local tissue.
clinical classifications:
Acne scars are classified into three basic types
depending on width, depth, and 3-dimensional architecture:
••Icepick scars: narrow (diameter < 2 mm), deep, sharply
marginated and depressed tracks that extend vertically to
the deep dermis or subcutaneous tissue.

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Boxcar scars: round to oval depressions with
sharply
demarcated vertical edges. They are wider at the
surface
than icepick scars and do not taper to a point at
the base. These scars may be shallow (0.1–0.5
mm) or
deep (≥ 0.5 mm) and the diameter may vary from
1.5
to 4.0 mm.

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••Rolling scars: occur from dermal tethering of
otherwise
relatively normal-appearing skin and are usually
wider than 4 to 5 mm in diameter. An abnormal
fibrous
anchoring of the dermis to the subcutis leads to
superficial
shadowing and to a rolling or undulating
appearance
of the overlying skin

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Other clinical entities included in this
classification are:
hypertrophicscars, scars are raised within
the limitsof primary excision,

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keloidal scars scars transgress the
boundary and may show prolonged and
continuous growth

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sinus tracts may appear as grouped open
comedones histologically showing a
number of interconnecting keratinized
channels.

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Prevalence of acne scarring:
One study reported acne scarring in 14% of
women and 11% of men among 749
patients aged between 25 and 58
years.Other publications suggest that
between 30% and 95% of patients with
acne develop some form of associated
scarring

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Treatment options:

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Topical agents:
Topical retinoids:
Whether or not the use of topical retinoids improves acne
scars that are already present has not been evaluated or
quantified in an appropriately controlled study.
Topical retinoids, such as tretinoin, have been shown to increase
dermal procollagen and collagen synthesis, and hence may
provide some benefit in preventing scar development and
potentially reduce the extent of scar formation that is in
progress (“unfixed scarring”(.
there is no cogent evidence demonstrating that topical retinoids
reduce scars that are already fully formed in the dermis (“fixed
scarring”(.

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•Topical antimicrobial agents:
•Of no benfit on fixed scar.
•Topical corticosteroids:
•Intralesional triamcinolone injection for
treatment ofhypertrophicand keloidal scars is
well established
•Long-term topical corticosteroid application is
not recommendedas local side effects, such as
atrophy and telangiectasia

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Superficial peeling:
••Very useful for treating pigmented
macular scars
••Useful for improving boxcar scars
••Improve active acne lesions
••Can be utilized for dark skin

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Superficial peelings include salicylic acid,
25% to 30%; glycolic
acid, 70%; piruvic acid, 40% and/or 50% to
60%; trichloracetic
acid, 20% to 30%; and combination of
salicylic acid or Jessner
peel with trichloracetic acid

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Pathophysiology
Supercial peelings are utilized to induce a
damage limited to
the epidermis and papillary dermis. This
results in epidermal
regeneration and postinflammatory collagen
neoformation

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Controindications
Controindications to superficial peelings include
••connective tissue disorders
••active skin disorders on the treatment sites
••history of treatment with systemic retinoids in
the previous
4months
••oral anticoagulant treatment
••pregnancy

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Photographic documentation
It is mandatory to obtain good-quality
pictures before starting
the procedure. This is an essential
documentation for follow-up
and for possible medicolegal issues

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Superficial peels are a cosmetic procedure that has the purpose of
exfoliating the skin through the application of chemicals that induce
skin irritation and damage.
••Expect severe burning during the procedure. This will usually last for
3 to 4 minutes.
••Expect skin redness for 2 to 3 days
••The skin will turn red brown and start to peel, 2 to 3 days after
peeling. Though rare, you can expect blisters and crusts.
••The procedure can cause pigmented or white spots that are usually
temporary and resolve in 1 to 3 months. In some skin types,
however, these
pigmentary changes may persist and require specific treatments.

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••For the first week after procedure apply a moisturizer 3
to 4 times a day.
••Don’t scratch or remove the scales as it may result in
scarring.
••Avoid sun exposure, as it will cause development of
pigmentary spots. Wear a high-protection sunscreen all
the time for at least 2 months after
procedure.
••Superficial peels improve the skin, but may not
completely eliminate acnes scars
••You may need to repeat the procedure 3 to 6 times for
optimal results.

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Boxcar scars before (A) and
combined 25% salycilic acid and 30% trichloracetic acid peeling.
after (B) 5 sessions with

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Boxcar scars before (A) and after (B) 5 sessions with 25% trichloracetic acid peeling.

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•white frosting indicates that it is time to neutralize with cold water.

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Medium depth and deep peeling:
Agents include:
Trichloroacetic acid (TCA) , Croton oil,
septisol, water, vegetable oils (glycerin,
olive, sesame.

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before and (B) 4 weeks after deep peeling (Exoderm method combined with mechanical de

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Dermabrasion for acne scars:
Dermabrasion is one •• of the most effective therapies for
acne scars
••Dermabrasion involves mechanically removing the
epidermis
and papillary dermis, creating a newly contoured
open wound to heal by second intention
••Reepithelialization of dermabraded skin occurs by
upward migration of cells from the adnexal structures
including hair follicles, sebaceous glands, and sweat
ducts.

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••Patient selection is key to obtaining excellent
results.
••Patients must have realistic expectations of the
anticipated
improvement, possible side effects, and potential
complications of dermabrasion prior to treatment.
••A familiarity with perioperative care and proper
operative
technique is instrumental to optimal cosmetic
outcomes.

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Dermabrasion of acne scars. (A) Severe
acne scarring present in an African
American male prior to dermabrasion.
(B) Postoperative appearance of the treated
area. (C)Appearance of the treated area
4weeks after dermabrasion.(D)Moderately
severe acne scarring present in a
Caucasian female. (E) Appearance of the
treated area 12 weeks after dermabrasion

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Endpieces commonly used in dermabrasion. From left
to right, wire brush, diamond fraize and cone-shaped diamond
fraize.

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Photograph demonstrating correct hand position of
the operator on the dermabrasion hand piece

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Fillers and fat transfer for treatment of acne scarring:
Better used in atrophic depressed scars.
Agents include:
Collagens
Zyderm, Zyplast, Cosmoderm, Cosmoplast, Evolence, and
Evolence Breeze are all collagens.
Hyaluronic Acids
Poly-L-Lactic Acid
Calcium hydroxyapatite

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Fat Transplantation
Fat transfer can be helpful in acne scarring by
restoring the loss of subcutaneous fat and
replacing volume, which stretches the overlying
skin and distends the acne scars. Patients who
are particularly good candidates for fat
transplantation include the acne-scarred patient
who has a thin, atrophic face. Many of these
older patients can benefit from a pan-facial
lipoaugmentation concurrent with the specific
injections designed to minimize the acne
scarring.

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A) Before and (B) 2 weeks after treatment with injectable bovine collagen
injected intradermally into the atrophic scars

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Needling: useful technique for acne scars
treatment
as an alternative to laser, chemical peelings,
and
dermabrasion.

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••Induction of new dermal collagen synthesis and
deposition
by activation of a local inflammatory response.
••The skin is not damaged. The epidermis and
particularly
the stratum corneum remain intact.
••There are no risks of hyperpigmentation.
••The healing phase is short and the treatment
can be
Repeated

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Method:
Skin needling is a procedure that involves using a
sterile
roller comprised of a series of fine, sharp needles to
puncture
the skin. Performed under local anaesthetic with
sedation, the
device is “rolled” over the surface affected by acne
scars to create many microscopic channels deep
into the dermis of the skin, which stimulates your
own body to produce new collagen.

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Indications
–Acne scarring: By treating acne rolling scars (Grade
2–3)with skin needling, the skin becomes thicker,
and the results are superior to dermabrasion.
–Scars, if they are white, they can become more skin
colored.
–To restore skin tightness in the early stages of facial
aging.
–Stretch marks.
–Fine wrinkles.
Lax skin on the arms and abdomen

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•Application of a topical anesthetic (EMLA)
on the facial skin in a patient affected with
acne scars

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Dermaroller

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The professional device is rolled on the areas affected
by acne scars in all possible directions

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in a
female patient after skin NeedlingFacial acne scars

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Fractional photothermolysis for acne
scars:
Nonablative and ablative devices for the
treatment of acne scars:

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Surgical techniques: Excision, grafting, punch
techniques, and subcision:
Patient characteristics that are possible
contraindications for surgical scar treatment
History of poor wound healing or tendency toward
keloid
formation/hypertrophic scarring
Unreasonable expectations for improvement
Active or recently resolved acne lesions

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••Subcision: is a simple, well-tolerated procedure capable of
producing long-term improvement of rolling acne scars.
Indication
This technique is best used to treat rolling acne scars with normal-
appearing overlying skin and a lack of sharply delineated
borders. It is contraindicated for areas of active infection and
in patients with bleeding diathesis or a tendency toward keloid
formation. Other cutaneous depressions, such as rhytids,
depressed skin grafts, surgical wounds, and cellulite dimples are
also considered valid indications for subcision.

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Immediately following subcision, there may be
bleeding and ecchymosis at the treated sites. This is
expected,
and it may be beneficial in promoting the formation of new
collagen beneath the depressed scars

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collagen beneath the depressed scars
••Dermal grafts are autologous implants
that may provide
permanent augmentation of depressed acne
scars.

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Indication
Dermal grafting is indicated for the correction of broad (3
mm–2 cm in diameter) and linear scars that are soft and distensible.(
17,19)Like subcision, dermal grafting can augment
depressed scars while leaving the overlying epidermis largely
intact, so it is best suited to treat scars with normal overlying
skin and a lack of sharp walls. Dermal grafting has also been
used to augment wider, deep rhytids such as nasolabial folds
and glabellar creases

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••Excision and punch techniques remain
the treatments of
choice for deep, sharply punched-out acne
scars.

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Thank you