1. Acne scarring
Dr Paul Charlson President British College of Aesthetic Medicine
GPwER in Dermatology and Medical Director
Skinqure and Intoskin Clinics Welton Leeds Chelsea and Canary Wharf

2. Myth – acne scaring is just “cosmetic”
“I have not looked in the mirror in years, and is painful not to be able to do that, and that is a direct result of acne, the acne scarring.”
“I think that if I had more self-esteem about the way I looked, I think I would have been more outgoing. I would have gone to more parties”
“Our study showed that post-acne scars have a significant negative effect on the QOL of young adults. It highlights the need to increase public awareness of acne vulgaris and its sequelae through education programs and advocating early treatment to reduce the risk of scarring.”
J Cutan Aesthet Surg Jul-Sep; 8(3): 153–158.
The Impact of Post-Acne Scars on the Quality of Life Among Young Adults in Singapore

3. Myth – Acne scaring is not treatable or preventable
Treatment can have good results – up to 75% reporting good to excellent
Even a “medical failure” might please the patient
Early treatment will reduce incidence of scarring
Picking spots may increase scarring

4. Who gets acne scarring?
Nearly all patients get some degree of scarring
Men are more likely to get truncal scarring and this can often be hypertrophic or keloid
There is a correlation between severity of acne and degree of subsequent scarring
Scarring is explainable by the depth and severity of the inflammation within the active acne lesion and individuals ability to heal
There is a lag time of up to 3 years from comedone to scar

5. HISTORY
Which aspects of the patient's scarring are the most bothersome to him/her?
How distressed is the patient about his or her scars?
What are the patient's goals for treatment?
Have any prior procedures been performed to treat the scars?
Has the active acne cleared completely? How recently did the acne clear?
Was isotretinoin used? How recently was it discontinued?
Is there a history of postinflammatory hyperpigmentation (PIH)?
Is there a history of keloids or hypertrophic scars?
PHYSICAL EXAMINATION
Direct overhead lighting is optimal
Have a mirror for the patient to point out lesions
Evaluate for active acne
Define types of scars (icepick, rolling, boxcar, severely atrophic/sclerotic)
Assess color (hypopigmentation, hyperpigmentation, purple/red discoloration)
Assess depth of the lesions
Stretch skin to see if scars disappear
Palpate for underlying fibrosis
Evaluate skin type (types III–V have increased risk of PIH with most procedures)

6. Goodmans 4 point acne scarring scale
GRADE 1: MACULAR
• Erythematous, hyper-, or hypopigmented marks
GRADE 2: MILD DISEASE
• Mild atrophy, can be covered with makeup or facial hair
GRADE 3: MODERATE DISEASE
• Moderate scarring, not covered by makeup but can be flattened by manual stretching of the skin
GRADE 4: SEVERE DISEASE
• Scarring not flattened with manual stretching of the skin

7. Types of acne scar
1. Macular marks – not true scars PIE post inflammatory
erythema
2. Atrophic scars- rolled, ice pick, boxcar, atophic macules
3. Raised – hypertrophic or keloid scars
4. Other pigmentary issues – hypopigmentation, persistent post
inflammatory hyperpigmentation.

8. Pigmented Marks PIE – post inflammatory erythema-blanches on pressure
PIH – post inflammatory hyperpigmentation

9. Treatment of PIE marks They fade over six months
Regular sun protection
Vascular laser

10. Treatment of PIH Inhibit tyrosinase – reduce melanin production
Increase cell turnover – spots fade faster
Block the sun
Arbutinin, Hydroquinone,azeliac acid kojic acid, liquorice root extract – all inhibit tyrosinase
Tranxemic acid and Niacinamide also prevent melanin production
AHA , retinoids- increase cell turnover

11. Main types of Atrophic Acne Scar

13. Rolling Scars Gently slopping sides rolled edges
Fibrous bands of tissue develop between the skin and the subcutaneous tissue below. These bands pull the epidermis, binding it to deeper structures of the skin.

14. Depressed fibrotic boxcar scars
Steep sides often larger, firm to touch. Inflammatory breakout destroys collagen, tissue is lost. The skin over this area is left without support, and a depressed area is created. Boxcar scars may be superficial to severe, depending on the amount of tissue lost

15. Treatment Planning Treatments are often long term and combination
Expectations and goals- psychological assessement
Financial considerations
Time constraints
Downtime
Non ablative laser or micro-needling better than fractional ablative
Excision likely to heal quicker than subcision or ablative resurfacing

16. Subcision 18 G Nokor needle Topical / local anaesthetic
Inserted bevel upwards into deep dermis and then back and forth and fan like motion.
Only allow a small haematoma to form
Ice and pressure
Bruising and swelling are significant

18. Dermaroller / Dermal Pen
Percutaneous collagen induction
Safe and minimal downtime
Takes six months and sometimes several treatments required
75% show good or excellent result
Best with shallow to medium depth scars

20. Dermaroller treatment

21. Dermaroller

22. Laser
Lasers are usually fractional where there are islands of untreated skin as this reduces downtime.
Ablative lasers affect the surface of the skin whilst non ablative work have less epidermal effect reducing downtime but are less effective in a single treatment
Good improvement and can treat a range of scars
Deeper scars better treated with more ablative laser
Downtime up to 2 weeks depends on type
Expensive and cannot use in type 5 and 6 skin

25. CROSS TCA Chemical reconstruction of scars
70-100% TCA for 10 seconds or when frosting occurs- wash off with saline
Often need to repeat up to 5 times
Care in pigmented skin as hyperpigmentation can occur

26. Cross TCA

27. Dermal fillers Soft scars are filled with a Hyaluronic acid filler
Tether scars are subcised using a Nokor needle first. It bruises – Then filled – 90% are improved

28. Surgery Good for isolated ice pick scars
Use a punch biopsy and suture or glue
Punch elevation
In larger ones graft a small area of skin
Good result

29. Icepick Scars Small jagged scars – steep sides
Develop after an infection from a cyst or other deep inflamedblemish works its way to the surface. Skin tissue is destroyed, leaving a long column-like scar.

30. Treatment of rolling scars
Subcision
Dermal filler after subcision
Microneedling
Fractional laser – ablative or non ablative

31. Treatment of Boxcar scars
Cross TCA – small lesions
Punch excision for small deep scars
Punch elevation –moderate medium sized scars
Punch grafting – deep scars
Ellipse incision
Skin needling
Fractional laser – choice of ablative laser or non ablative

32. Treatment of Ice Pick Scars
Cross TCA
Punch Excision

33. Keloid acne scars Difficult to treat Often recur after treatment
Can use pulsed dye laser
Inject with steriod + or - cyrotherapy

35. Keliod after pulsed dye laser