View metadata, citation and similar papers at core.ac.uk brought to you by CORE Acta Dermatovenerol Croat 2010;18(3):171-175 REVIEW Current Therapeutic Approach to Acne Scars Aleksandra Basta-Juzbašić University Hospital Center Zagreb, Department of Dermatology and Venereology, School of Medicine University of Zagreb, Zagreb, Croatia Corresponding author: SUMMARY The occurrence and incidence of acne scarring is Professor Aleksandra Basta-Juzbašić, MD, PhD different. Lasting for years, acne can cause both physical and psychological scarring. Scarring frequently results from severe University Hospital Center Zagreb inflammatory nodulocystic acne but may also result from more Department of Dermatology and Venereology superficial inflamed lesions or from self-manipulation. There are School of Medicine University of Zagreb two general types of acne scars: hypertrophic (keloid) scars, and Šalata 4 atrophic (icepick, rolling and boxcar) scars. The management of acne scarring includes various types of resurfacing (chemi- HR-10000 Zagreb cal peels, lasers, lights, cryotherapy), use of dermal fillers, and Croatia surgical methods such as dermabrasion, subcision or punch ex- cision. Individual scar characteristics, including color, texture and morphology, determine the treatment choice. Combining treat- ment methods may provide additional improvement compared Received: May 31, 2010 with one method alone. It should be noted that none of the cur- Accepted: June 30, 2010 rently available treatments can achieve complete resolution of the scar. The best method of preventing or limiting scarring is to treat acne early enough to minimize the extent and duration of inflammation. KEY WORDS: acne scars, treatment INTRODUCTION Acne vulgaris is one of the most common skin nodules. In addition, patients may have scars of diseases. It affects 80% to 85% of teenagers and varying size and type. The characteristic scar of young adults (1). In mature adults, up to 7% may acne is a sharply punched-out pit. Less common- have acne persistently into the mid 30s or 40s (2). ly, broader pits may occur, and sometimes, espe- Acne is a disease of the pilosebaceous unit, in- cially on the trunk, the scars may be hypertrophic volving abnormalities in sebum production, follicu- (3). Lasting for years, acne can cause both physi- lar epithelial desquamation, bacterial proliferation, cal and psychological scarring (4) (Figs.1 and 2). and inflammation. The disease is characterized by a great variety of clinical lesions either noninflam- matory or inflammatory. The noninflammatory are ACNE SCARRING open and closed comedones, and the inflamma- The occurrence and incidence of scarring is tory vary from small papules with an inflammatory not well understood. Goodman has reported an areola to pustules, and large, tender, fluctuant 11% frequency of acne scars in men and 14% in 171 Basta-Juzbašić Acta Dermatovenerol Croat Acne scars 2010;18(3):171-175 Figure 2. Close view of acne scars resembling the moon face. vascular changes caused by acne are often tem- porary; however, changes in texture caused by disruption of collagen are often permanent (10). Figure 1. Impressive scars disfiguring the entire face of the patient. TYPES OF SCARRING women based on clinical examination by derma- There are two general types of acne scars, de- tologists (5). Layton et al. showed a correlation fined by tissue response to inflammation: scars between the severity of scars and the duration of caused by increased tissue formation and scars delay between the onset of acne lesions and the caused by the loss of tissue (11). start of treatment, emphasizing the need for early aggressive therapy (6). Hypertrophic scars The considerable variation in scarring that oc- curs in different individuals suggests that some Hypertrophic and keloidal scars are associated people are more prone to scarring than others. with excess collagen deposition and decreased Scarring frequently results from severe inflamma- collagenase activity. Hypertrophic scars are typi- tory nodulocystic acne but may also result from cally pink, raised and firm, with thick hyalinized more superficial inflamed lesions or from self-ma- collagen bundles that remain within borders of nipulation (7). the original site of injury (10). Keloids form a red- dish-purple papules and nodules that proliferate Severity is related to both the depth in the der- beyond the borders of the original wound. Histo- mis/pilosebaceous unit where inflammation and logically, they are characterized by thick bundles wound healing occur and the duration of inflamma- tion. Erythema and pigmentation changes repre- sent epidermal damage whereas atrophic, hyper- trophic and keloidal scars indicate dermal damage (5). Scar form at the site of tissue injury and skin initiates a cascade of wound healing events, which progresses through 3 stages: inflammation, gran- ulation tissue formation, and matrix remodeling (8- 10). The first step in wound healing is coagulation and inflammation. In the second step, damaged tissues are repaired and new capillaries formed. In the third step, which takes long, fibroblasts and keratinocytes produce enzymes determining the architecture, which leads to the development of atrophic or hypertrophic scars. When the healing response is too exuberant, a raised nodule or fi- brotic tissue is formed; inadequate response re- sults in diminished deposition of collagen factors Figure 3. Keloid scar can sometimes be improved with and formation of an atrophic scar. Pigmentary and cryotherapy. 172 ACTA DERMATOVENEROLOGICA CROATICA Basta-Juzbašić Acta Dermatovenerol Croat Acne scars 2010;18(3):171-175 Figure 5. Atrophic scars on the dorsal region. Figure 4. Atrophic scars as a residue after isotretinoin They include chemical peels, dermabrasion, la- treatment. sers, selective photothermolysis, cryotherapy and electrosurgery. Surgical methods include excision, of hyalinized acellular collagen arranged in whorls punch elevation and subcision. Dermal fillers may (11) (Fig. 3). Hypertrophic scars and keloids ap- be used to plump up atrophic scars, and makeup pear predominantly on the back, shoulders, ster- may be used to conceal scars. For best results, nal region and over the jaw angles. a combination of techniques and procedures may be needed (11). Individual scar characteristics, in- Atrophic scars cluding color, texture and morphology, determine the treatment choice (13). Atrophic scars occur predominantly on the face A wide variety of treatments have been used (Fig. 4) and more rarely on the trunk (Fig. 5). Jacob against hypertrophic scars. Surgical excision was et al. have proposed an acne scar classification used early, but it is associated with a high recur- scheme that divides atrophic scars into 3 types: rence rate. Radiation therapy has also been used, icepick, rolling, and boxcar. They suggest that the most important features of scars are width, depth, alone or in combination with surgical excision. In- and three-dimensional architecture (12). jection of corticosteroids is also a therapeutic op- tion that some consider a mainstay of treatment Icepick scars are narrow, less than 2 mm in (14). Hypertrophic scars my respond better than diameter, punctiform and deep. The opening is keloids. A potent steroid can be applied under wider than the deeper infundibulum, forming a “V” polythene occlusion daily for eight weeks (15). shape. The 585-nm pulse dye laser (PDL) has been used Rolling scars are usually wider than 4 to 5 mm with good results to treat hypertrophic scars and with dermal tethering of the dermis to the subcutis. keloids, reducing erythema, pliability, bulk and These scars give a rolling or undulating appear- dysesthesias, with few side effects. Thick keloids ance of the skin, forming an “M” shape. may respond best to PDL plus intralesional cor- Boxcar scars are round or oval with well-estab- ticosteroid or 5-fluorouracil injections (13). Cryo- lished vertical edges. They tend to be wider at the therapy is also widely used, but may be followed surface than an icepick scar and do not have the by pain, hypo- or hyperpigmentation. tapering V shape. They can be visualized as a “U” Atrophic scars can be treated with numerous shape with a wide base. Boxcar scars can be shal- nonsurgical resurfacing techniques and different low or deep (12). surgical techniques. Dermabrasion can provide effective treatment for acne scars, but it can be TREATMENT OF SCARRING associated with significant pain and recovery time, The aim of scar treatment is to give the skin pigmentary alterations and milia (12). Dermabra- a more acceptable physical appearance. Resur- sion usually fails to improve icepick or deep box- facing techniques destroy the epidermis and allow car scars. Microdermabrasion is well tolerated but for re-epithelialization with collagen remodeling. of limited benefit in acne scaring. Medium-depth ACTA DERMATOVENEROLOGICA CROATICA 173 Basta-Juzbašić Acta Dermatovenerol Croat Acne scars 2010;18(3):171-175 chemical peels are most useful for correcting The occurrence of scarring is hard to predict. At small depressed scars. It should not be used for present, the best method of preventing or limiting icepick scars or deep fibrotic scars (11). Lasers of scarring is to treat acne early enough to minimize various wavelength and intensity may be used to the extent and duration of inflammation. Present recontour scar tissue and reduce the redness of data show that the degree and duration of inflam- skin around healed acne lesions (10). The choice mation are directly related to the likelihood of scar- of optimal laser system and settings depends on ring. There are a variety of scars and treatment the characteristics of scarring present (8). options that can be used to achieve significant There are 3 primary surgical techniques for cosmetic improvement, but it must be noted that acne scars: excision, punch elevation and subci- none of the currently available treatments can sion (11). Scattered individual icepick scars may achieve complete resolution of the scar. Combin- be removed by punch excision of each scar. It ing treatment methods may provide additional im- may be used for narrow deep boxcar too. Punch provement compared with one method alone.