Erasing the Scars of Acne
Pimples may be the source of jokes during the teenage years, but anyone who’s had severe acne knows that it’s no laughing matter. For many people, the scars of acne linger long after the pimples have cleared up. Those scars can not only be physically disfiguring, but can also cause psychological distress each time a person looks in the mirror. But new dermatologic techniques, including the use of lasers, are starting to help erase acne’s outward–and inner–scars.
Not Just For Teens
Most of us had at least one breakout during our teen years. But according to the American Academy of Dermatology (AAD), for as many as 70 million people, acne persists from the teens into the 20s, 30s or even beyond (men are more likely than women to develop severe, long-lasting acne).
Acne results when the sebaceous glands inside hair follicles get plugged up by the oil they produce, called sebum, and by dead skin cells. The clogged follicle becomes a breeding ground for bacteria, called Propionibacterium acnes (P. acnes), which triggers inflammation in the skin that leads to breakouts.
Small acne lesions like pimples, blackheads, and whiteheads don’t usually leave scars. It’s the large, pus-filled nodules or cysts that leave pits or crater-like scars.
“The inflamed acne lesion can cause an extreme reaction, which produces a large amount of pus and forms a nodule. The nodule can penetrate deeply into the skin and be very painful. As the nodules heal, the process of repair creates a scar that forms an indentation in the skin,” explains Dr. Jeffrey Dover, associate professor of dermatology at Harvard Medical School.
Zapping Acne Scars
Lasers are commonly used to zap acne scars. The beams of light that are absorbed superficially by the water in skin–depending on the wavelength–vaporize a thin layer of skin. When new skin grows back, it’s smoother, and scars are much less noticeable. Two types of lasers are used to resurface scarred areas of the face: the pulsed carbon dioxide (CO2) laser and the Erbium:YAG laser.
“The CO2 laser produces more heat, and the amount of tissue removed with each pass of the laser is deeper. Because the energy penetrates deeper into the skin, it tightens the collagen fibers, causing depressed acne scars to elevate and the skin looks more normal,” explains Dr. Bruce Katz, Associate Clinical Professor of Dermatology at the Columbia University College of Physicians and Surgeons in New York.
“On the other hand, the Erbium:YAG laser emits light through short bursts of energy that allows very precise sculpting of smaller, irregular scars. Because the laser doesn’t penetrate as deeply, recovery time is usually 7 to 10 days, compared with 12 to 14 days for the CO2 laser.” The two lasers are being used together with better results, he says. In most cases, only one treatment is needed with either laser to achieve lasting results.
However, laser resurfacing is not 100% effective for acne scars. “Laser skin resurfacing can improve acne scars by 40% to 50%, but many patients may still be left with some scarring. Sometimes, we’re able to do a second resurfacing procedure a year later, and the appearance of skin improves even more. Lasers are not magic, but it’s a vast improvement over what we were able to do for acne scarring years ago,” remarks Dover.
Filling in the “Craters”
Depressed, crater-like scars from cystic acne can be filled in with bovine collagen or transfers of a patient’s own body fat.
Autologous fat transfer involves harvesting fat tissue from another part of the patient’s body, using a needle under local anesthesia, then injecting small amounts just below the surface of a depressed acne scar to elevate it. The drawback is that the replaced fat reabsorbs into the skin, so results typically last just 6 to 18 months, says Katz. Permanent results can only be achieved with multiple procedures, or using other materials.
“There are a variety of different filler substances that we can use, including a number of collagens that have been newly developed,” says Katz. “These include Hylaform, restalane and dermalife, which are being tested but are not yet on the market.” Soft tissue fillers like collagen are injected in a similar fashion as an autologous fat transfer to raise depressed acne scars.
Special Surgery for Deep Scars
Some patients have “ice-pick” or deep-pitted scars, or rolling scars, which are not easily corrected by lasers or fillers. Ice-pick scars are removed in a procedure called punch excisional surgery. “We can use a little punch or a scalpel to cut out that depressed scar and either stitch it closed to eliminate the pit, or replace it with piece of skin from behind the ear,” says Katz.
“What we call ‘rolling scars’ have fibrous bands which anchor the skin down underneath, and that creates a depression. There’s a procedure called subcision, or ‘underming,’ where a sharp instrument is used to cut these fibrous bands which release the skin,” explains Dover.
The number of treatments vary with the amount and extent of the scarring. Six weeks after the last excision or subcision procedure, laser resurfacing is usually done to smooth away small scars formed by the surgery. In some cases, fillers may still be needed.
Mild Scarring Helped By Microdermabrasion
Years ago, acne scars could only be erased with dermabrasion, literally sanding down the skin with a rotating wire brush or spinning diamond roller. The resulting open wound healed in 1 to 2 weeks, and a new, smoother layer of skin would grow to replace the abraded skin. Dermabrasion is still done, using local anesthesia, for raised acne scars.
There’s now a less drastic technique called “microdermabrasion.” Instead of a wire brush, aluminum oxide crystals whirling in a vacuum tube gently scrape away a more superficial layer of scarred skin. The procedure doesn’t create an open wound, and damaged skin is removed and new cell growth is stimulated at the same time.
“Microdermabrasion is a quick procedure that leaves the patient with only minimal redness,” explained Katz. “Because of the superficial nature of this procedure, patients with acne scarring will often need multiple treatments.” The best candidates are people with very mild scarring; but the results are less dramatic than with traditional dermabrasion.
Preventing Acne Scars
For many people, acne scars can be lessened or even prevented.
Topical antibiotics kill P.acnes on the skin’s surface, but they don’t penetrate deeply. Systemic antibiotics get into the sebaceous glands from the inside to kill bacteria. Oral derivatives of vitamin A called retinoids normalize the way skin grows and sheds cells, and help unclog pores.
“Accutane stops sebum production, kills acne bacteria, it alters the pore which is probably abnormal and tends not to block. And we believe it also has anti-inflammatory effects,” explains Harvard’s Jeffrey Dover. “We usually give Accutane once for a four-month course. Over 60% of people who take the drug never need any other form of therapy for acne. Accutane is a potential cure for acne. When used early it can prevent scarring.” But it is not for use in women who are pregnant or plan to get pregnant while taking the medication.
Article By: Rita Baron-Faust, Medical Writer
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