Physical treatment is a part of acne therapy and is essential
to obtain maximum therapeutic results. Acne scar treatment forms
an important part of physical treatment.
Types of scars
Physical treatment for scars depends on the type of scar determined
by their shape, number, depth, localization and duration. It also
depends on the patient’s skin and localization of the lesions.
Macules or “pseudoscars” are flat reddish spots in
the final stage of the most inflamed lesions. The site is pigmented.
It occurs more in darker skinned people.
Hypertrophic scars or keloids result from increased tissue formation
and excessive collagen.
The more common are four types of scars caused by loss of tissue:
- Ice pick scars occur on the cheek, look like someone has used
a little ice pick. The lesions have jagged edges.
- Box scars are
large, U shaped depressed fibrotic scars with sharp edges
and steep sides.
- Rolling scars are deep and soft and have gently
rolling edges which merge with the skin.
- Atrophic scars are
small, white and soft and barely raised above the surrounding
At the outset the patient should be told about the risks and
benefits involved, since the outcome varies. Complete erasure
of the scar may not be possible and for best results multiple
treatments may be required.
The patient’s medical history must be thoroughly examined.
Treatment should not be done on patients who have recently undergone
oral therapy, have a history of keloids, non acne or persistent
Types of treatments
Collagen injections: Collagen is injected under the skin to fill
deep soft scars. It is not suitable for ice pick scars and keloids.
The cosmetic effect lasts for three to six months and may be extended
with further injections.
Autologous fat transfer: Here depressed scars are raised by injecting
fat under the skin surface - taking fat from another part of the
body. Since the fat is absorbed in 6 to 18 months the procedure
must be repeated.
Dermabrasion: Here under local anesthetic, a brush or a fraise
removes the surface skin and changes the contours of the scars.
Superficial scars can be completely removed and the depth of deep
scars can be reduced. The treatment does not work on ice pick
scars, making them more prominent, and on scars which are wider
under the skin than on the surface. It often does not give the
best results on U shaped scars. In dark skinned patients it causes
coloration needing further treatment.
Microdermabrasion uses aluminium oxide crystals passing through
a vacuum to remove surface cells, avoiding further wounds. Microdermabrasion
can be used on small and faint scars but it is not powerful enough
for other acne scars.
The three types of chemical peels used are superficial, intermediate
and deep peels.
Superficial peeling has the highest risk-benefit ratio. It can
remove macular scars and the accompanying pigmentation. The skin
gets a healthier complexion and the size of the skin pores is
reduced. Ice pick and U shaped scars can also be given this treatment.
The skin has to be prepared for 15 to 30 days before treatment
with keratolytic products and depigmenting creams. The side effects
include erythema folliculitis, flare of acne lesions and hypopigmentation
Intermediate and deep peeling have a lower risk-benefit ratio
and the effect on atrophic scars is mild and for a shorter duration.
They have no effect on keloids. The risks of scarring and pigmentation
Varieties of laser treatment are possible depending on the intensity
and wavelength of the lasers. Laser therapy is non-invasive, does
not require anesthesia and is less painful.
Results from laser surfacing have been encouraging. However,
erythema occurred in all patients and in 54% it lasted for longer
than three months. Hyperpigmentation occurred in 29% but faded
within 3 months. Other problems requiring medical intervention
were present in 54% and lesion flare-ups occurred in 29%. Longer
wave length lasers achieved quicker results.
The pulse-dye and intense pulse light laser can raise depressed
scars and improve hypertrophic facial scars. High energy pulsed
CO2 lasers have shown good results with atrophic and shallow U
shaped scars, improving skin appearance by giving it a more homogenous
There are several types of skin surgery.
Punch excision can treat ice picks and deep scars simultaneously
if they are at least 4 to 5mm. apart.
Punch elevation combines punch excision and grafting without
causing skin color or texture mismatch. A necessary condition
in this treatment is that the scars should have sharp edges and
normal bases. Box car scars therefore cannot be treated with this
Skin grafting is especially needed to close the defect of unroofed
Each type of scar has an optimal treatment method. Sometimes,
for example, punch excision and elevation needs to be combined
with laser resurfacing to improve skin appearance.