acne scar treatment

Still trying to get results from microneedling RF for acne scars?

Still doing only one type of laser when it’s already proven that combination lasers work better?

Have you been told that acne scars can only be treated after acne is cured and there is no all-in-one cure?

The days of pimple breakouts are finally over but they’ve left with you many scars that you would just do better without. Ongoing breakouts make acne scar treatments feel like you are running a treadmill – new scars keep forming even as you are treating the existing ones.

This update gives you the latest and most effective treatments used for acne scarring, explains why some will tell you that scars cannot be treated with active acne, and what treatments actually can treat both at the same time!

Acne Scars Are A Healing Process

Acne scarring is basically forming new collagen fibres in your skin to repair the damages, such as the rupturing of a pimple. However, repair work simply wouldn’t be a “good as new” situation, at least when severe damage happens to your skin.

There are three types of atrophic acne scars, sometimes they need to be felt to confirm diagnosis, but these are some general features:

Acne scar subtypes

Acne Scar Types

  • Box scars are broad depressions with sharply defined edges.
  • Ice pick scars are narrower versions of box scars and may be narrower than they are deep.
  • Rolling scars are broad depressions that have rounded, sloping edges.

Preventing Acne Scars

Prevention is better than cure, so acne should be treated early to minimize scarring in the future. I use a mix of medicines, creams and lasers to help with it and the results are much faster than using either modality alone. Treating acne immediately will save you money and time treating the scars they leave behind. Acne treatments work immediately from the first session if they are done properly and if you do not see results from your acne treatments from repeated treatments, I would genuinely advise you to stop wasting money.

Can Active Acne be Treated at the same time with Scars?

If you are having active acne and want to treat your scars, there is only one type of laser/medical equipment proven to effectively treat both active acne and old acne scars. The usual ablative lasers or even the newer fractional radiofrequency devices are NOT the best option – they either penetrate or ablate the skin surface, making it more likely for the bacteria in active acne to spread and worsen the condition. That laser of choice would be the Erbium Glass laser (1540-1550nm wavelength, also known as Fraxel Restore, Mosaic, De Oro). At this wavelength, this non-ablative fractional laser can target the inflammation of active acne, as well as stimulate deep skin layer collagen, all without hurting the skin surface!

Best Acne Scar Treatment in Singapore

That being said, if you already have acne scars, you should know that there’s still no “best treatment”. Simply because it is subject to:

  1. Type of acne scarring

Acne scars are textual defects that can occur in several possible layers of your skin. Superficial irregularities such as box scar edges would require more surface smoothening treatments, whereas deep layer scar tissue tethering that is present in rolling scars would require scar tissue separation and intense collagen stimulation. These require very different treatment types.

  1. Each individual’s skin type

Skin types also affect choice of treatment. I use 5 different fractional treatments in my clinic, 3 types of injectables for atrophic scarring and punch biopsy, sometimes in combination, because different options are needed for one type of scar in individuals with different skin types.

For example, someone with box scars and normal skin may benefit from aggressive laser ablative treatment, but someone with sensitive skin and box scars may do better with other modes of treatments instead.

Generally, I split acne scar treatments to damaging and regenerative treatments:

DAMAGING Acne Scar Treatments

Medical peel, laser/device skin ‘resurfacing’ and surgical excision cause damage in order to stimulate repair. Full beam lasers or peels (such as the TCA peel) to ablate (burn) the entire scar surface gives fastest results, but this involves a lot of downtime and too much risk, so is no longer popular. The TCA peel is still occasionally used for deep and small ice pick scars.

deep peel acne scar diagram

(Diagram showing ablative full beam laser or deep peel)

Fractional lasers damage small columns of skin leaving normal areas in between, so there is much faster recovery and much less side effects ( such as burns/infection/hyperpigmentation/scar worsening). However, because only small parts of the total scar area is treated with each session, multiple sessions are necessary.

Fractional lasers also split to:

  • Fractional ablative – works better on surface irregularities (box and ice pick scars)
  • Fractional non-ablative works better on deep tissue stimulation (rolling and box scars)
Fractional lasers types

(blue: fractional ablative, red: fractional non-ablative)

Most simple clinics would use only a fractional ablative laser because it’s possible to ablate so much such that it reaches the deeper irregularities as well. However that’s not optimal for Asian or darker skin types because of poor and prolonged healing and higher risk of side effects.

ablative lasers side effects

So many clinics who only use an ablative laser are forced to use it at a gentle superficial setting to minimise the downtime- this results in much lesser or even no results (I discuss this more at the end of this article), especially when there are many deep tissue defects.

superficial and deep ablative fractional resurfacing diagram

Combining non-ablative and ablative lasers can actually minimise downtime and maximise results – especially when there is a mix of surface and deep irregularities such as ice-pick and box scars (1)

epidermis

(1. Treatment with ablative laser needs to burn through multiple skin layers to reach deep irregularities. 2. This is much elegantly achieved by combining non-ablative laser with ablative laser)

The right type of lasers and the right combination is also important – not just do different scars need different lasers, different skin types need different lasers too! For example, a person with non-sensitive skin type but same type of scar as a sensitive skin type person can be treated more optimally with different laser! This is why my current practice uses 6 fractional skin resurfacing devices: fractional non-ablative erbium glass, fractional thulium (non-ablative to semi-ablative), fractional CO2 (ablative), fractional Picosecond ND:Yag (non-ablative to ablative mode), fractional microneedling and nanofractional radiofrequency. Every individual needs something different.

In short, what’s the damaging acne scar treatment of choice? It is an appropriate combination of deep and surface laser for your skin type- sometimes in the same session! Stop doing only one type of laser for your acne scars.

Punch Excision

Punch excision of acne scars are reserved for the more stubborn scars. These are usually the more tethered ice-pick and box scars, but can even be used for deep open pores. This needs to be done carefully as there is a risk of leaving a new scar after cutting off the old scar. I use micro-surgical instruments to treat these scars to minimise risks. Lasers are sometimes required before or after this procedure to improve outcomes.

Punch Excision

REGENERATIVE Acne Scar Treatment – Dr Chua’s Choice

Why is subcision with collagen stimulators and hyaluronic acid is so important? These are the REGENERATIVE treatments.

Subcision is a method aimed to break apart and loosen the tough scar fibres that are causing the indentation that you see on your face. These scars have not regenerated evenly and are pulling your skin downwards thus, causing the visible dip. After damaging the incorrectly healed scar tissues with subcision, collagen stimulators (fillers) are injected in small amounts to encourage proper repair of your skin and aid in the healing process.

subcision for acne scars

Fractional lasers cause damage to stimulate repair and allow skin renewal, but subcision with fillers improve scars by molecular regeneration. Research has shown that HA is pivotal in the wound healing process. It is more than just filling up the scars, these components aid in facilitating a faster and safer healing process. (2). Subcision with fillers complement laser treatments by providing enhanced result targeted especially at deep defects. They also improve other skin attributes such as moisture and sensitivity – lasers cannot improve moisture but instead usually result in temporary dryness; most lasers also result in temporarily increased sensitivity during its healing phase.

There are also some relatively new technologies (Enerjet, AirJet) that utilise strong air pumps to deliver fillers into deep skin layers without needles. These work very well for individuals with extremely tethered scars because the pneumatic acceleration of the air jet blasts compounds into the deeper layers of the skin, inducing a deep volumetric micro-trauma effect with an optimal spread of the collagen stimulator or hyaluronic acid. This is much more effective and explosive than the manual subcision work, and the dermal (skin) thickening achieved by Enerjet for atrophic scars has been proven to be much more effective than fractional lasers. However, they come with their own set of risks and should be used with care.

A common misconception is that fillers are only temporary and only keep the scars separated for the duration they are there. Apart from the healing effects of molecular regeneration, fillers actually also stimulate collagen production in these skin layers during the time they are present. This also means the scars never “revert back” to original state even after the fillers have been metabolised by the body. When patients ask me how long these subcision treatments last for, I always tell them it is a matter of perspective: it either lasts for a day, or forever!

Take home message: regenerative treatments with subcision can benefit nearly anyone with acne scars. They have long lasting effect beyond the temporary filling and are an important part of acne scar treatment. Newer methods of scar regeneration like Enerjet can be even more effective than old manual efforts.

Precautions and post-care matters

Precautions and skincare advice are way less sexy sounding and exciting, compared to state of the art machines like Fraxel, Fractional Pico or Enerjet that promise the world. They are no less important though. Treatment intervals, pre and post-treatment skincare, precautions during and after treatment all matter greatly for safe and successful treatment.

Cooling during treatment protects the skin surface, minimising downtime and unintended treatment of epidermal layer.

Cooling after treatment: minimises side effects that may occur due to heat, especially in sensitive skin types.

Clinics which are serious in their laser treatments usually use a few specialised cooling devices for greater safety and effectiveness.

laser skin treatment cooling

Skincare is also essential after treatments. You spend everyday with your own skin and good skin care is priceless. Sunblock, moisturiser are some important basic skin protectors, they become more important during the sensitive period immediately post-laser treatment. Occasionally, medical creams/products may be needed to minimise or treat inevitable mild side effects. Lastly, spacing out your treatments are very important for skin recovery. There is also newer research that shows there are optimal intervals to perform combination treatments or mixing subcision with laser treatments!

Bottom line precautions like pre and post-treatment skincare, cryo-cooling machines during treatment and proper skin cooling after laser are all critical for safe and successful treatment. Ask about these at your clinic when doing acne scar treatments!

Does Latest Treatment mean Better? How can you tell?

Don’t get me wrong, acne scars are NOT easy to treat. This is why whenever a new technology or treatment type is launched, it generates a lot of hype for scar sufferers and doctors alike. This makes it very important to sieve out what works from all that hype. Seasoned doctors and long-suffering patients would know what it is like to go through multiple technologies and see little to no results.

How do I assess the new treatments?

  • The first step would be reading and analysing available clinical evidence on the new technology. This is tricky because there is a lot of biased studies based on the commercial interests of big pharmas/machine makers. It is therefore very important to critic and analyse the clinical trial methods and any nuances in the process of the study, rather than simply draw the same conclusion as the author of the study.
  • I then assess the treatment protocol and concept suggested by the new technology. There are many machine companies such as Fotona, Endymed and Ascelpion (ProYellow) that base their products on good quality doctor developed protocols and scientific concepts. I measure the quality of new technologies by comparing the protocols behind them to current standards and available scientific knowledge.
  • The last step is the actual clinical testing of the product/machine on myself and then a group of volunteers

Does Fractional Radiofrequency Work for Acne Scars?

Fractional RF is one of the newer treatments proposed for acne scars, and many still claim they are the new generation of acne scar treatments, promising better results with lesser downtime. Fact or hype?

Most people don’t know that there are actually 2 types of fractional radiofrequency (RF) machines

  • Nanofractional RF (Endymed FSR, Venus Viva)
    1. Causes both surface ablation and deep layer heating
    2. Works well for certain types of acne scars
    3. Effective and safer replacement for Fractional Ablative lasers (3)
    4. Safer, less downtime, especially for Asian and darker skin types
    5. Usually cheaper and more affordable too
  • Microneedling RF (Infini, Intracel, Endymed Intensif)
    1. Relies of deep heating only, no ablation
    2. Minimal use for acne scars – studies shown even the gentle fractional non-ablative lasers alone more effective than Infini (4)
    3. Able to reach deep layers of facial tissues (3 to 5mm) and hence can help with lifting and tightening of fat and ligamental sagging

This was how I went about analysing it.

  • Papers of nanofractional RF show good effects with acne scars specifically, with lesser side effects when compared to other lasers.
  • Papers of microneedling RF show lesser effects than other lasers
  • Analysis of science:
  1. Nanofractional RF provides ablation safely, and also has deep tissue coagulation to help with deep dermal remodelling.
  2. However, microneedling RF only provides deep tissue coagulation at one layer with no ablative effect
  3. Advantage of microneedling RF to go to deep layers like 3.5 or 5mm is USELESS since facial skin thickness rarely exceeds 2.5mm!rf microneedling
  4. In fact, even deep acne scar defects rarely extend beyond 1.5mm deep (see diagram), hence it is a deep misconception that treatments that reach “very deep” are very useful!
  • Practical use and testing:
    1. Tested nanofractional RF gave good immediate textural resurfacing even from the first session with minimal downtime
    2. Tested microneedling RF options like Infini, Intracel- gave bruising when tested on myself persisted for beyond a week! The gentle erbium-glass laser that only gives a tanned appearance for a few days, and was proven more effective than microneedling RF in a clinical study (4). This means that even my gentlest laser in my arsenal of FIVE OTHER fractional machines, is stronger than microneedling RF.
    3. There were also minimal perceivable benefits to acne scars even after repeated treatments when testing on group of volunteers.
  • Decision made not to use microneedling RF for scars. This is consistent with many reports online and patient complains from other clinics about these devices having minimal effects on scars. Unless significant improvement made to the technology of microneedling RF for atrophic scars, I predict more and more reports will surface about the inadequacy of this relatively new treatment. Many experienced doctors are already speaking up about it and the false marketing behind the science.

Both Nanofractional and Microneedling RF options are used in the clinic.

  • Nano RF used for acne scars, especially those with darker skin or high risk for side effects
  • Microneedling RF almost never used for acne scars (since even the gentle lasers can do much better, and without any breaking of surface skin layer), and is hence only used for lifting and tightening of sagginess (beyond skin deep because its usefulness is really deeper)

Regarding fractional radiofrequency devices: nanofractional RF is very useful for acne scars, with lesser side effects than ablative lasers. Microneedling RF is not useful for acne scars, but may be used for facelifting.

Type of Acne Scar Treatment Way it works Most useful for which scar type and skin type
TCA Peels Chemically destroy skin layers of the scar Small ice-pick scars
Full beam ablative laser Laser vaporisation of scar tissue Ice-pick and box scars
Fractional ablative laser Fractionated beams of vaporisation Ice-pick and box scars
Fractional non-ablative laser Stimulation of collagen in deep scar tissues Rolling and box scars
Punch excision Surgical removal of scar Small to large ice-pick scars
Microneedling radiofrequency Stimulation of collagen in deep scar tissues Not very useful for scars
Nanofractional radiofrequency Vaporisation of scar tissue as well as stimulation of collagen in deep scar tissue Rolling and box scars
Subcision with collagen stimulators Severing of fibrous bands at centre of acne scar Rolling and box scars

Can Acne Scars be Cured 100%?

Who says acne scars cannot vanish? Many clinical studies nowadays set out to study only one specific treatment, in a population of individuals with various types of scars and various skin types. This is why results usually vary, and rarely show beyond 50-70% improvement.

In fact, if the wrong treatment type is undertaken, or if the technique of scar treatment is done wrong, there could be ZERO% results, or even worsening of scars! The operator skill behind all the techniques cannot be underrated – the correct laser setting, the proper needling technique and the microsurgery closure of punch biopsies.

To give a simple example, many repeated sessions of a under-powered fractional CO2 laser would only achieve surface brightening and exfoliation like a strong facial scrub – even 100 sessions of that treatment wouldn’t help acne scars!

When different treatments are used properly for the right type of scars and respecting the right skin type, results close to 100% IS ACHIEVABLE.

acne scar treatment before after

acne scar treatment before after

References:

  1. Sung Bin Cho et al; Combined fractional laser treatment with 1550-nm erbium glass and 10 600-nm carbon dioxide lasers; Journal of Dermatological Treatment 21(4):221-8 · February 2009
  2. Litwiniuk M et al; Hyaluronic Acid in Inflammation and Tissue Regeneration; Wounds. 2016 Mar;28(3):78-88.
  3. Goel A. et al; Use of nanofractional radiofrequency for the treatment of acne scars in Indian skin; J Cosmet Dermatol. 2017 Jun;16(2):186-192. doi: 10.1111/jocd.12311. Epub 2017 Mar 23.
  4. Chae WS et al; Comparative study on efficacy and safety of 1550 nm Er:Glass fractional laser and fractional radiofrequency microneedle device for facial atrophic acne scar; J Cosmet Dermatol. 2015 Jun;14(2):100-6. doi: 10.1111/jocd.12139. Epub 2015 Mar 23.