Management of Acne Scars – Facial and Truncal Acne Scars
Acne vulgaris is a common condition with a lifetime incidence of ever 80%. Acne scarring is an unfortunate, yet frequent sequela of acne. Any type of acneiform lesion, including comedones, papules, pustules or nodulocystic lesions, may result in scarring.
Acneiform lesions that have been manipulated are more likely to result in scarring. Truncal acne scarring is more common in males than females. Asian and black patients are especially acne conglobata, has a higher risk of leading to scarring.
Several factors may predispose a patient to acne scarring. Prolonged angiogenesis is seen in lesions that proceed to scarring compared to lesions that resolve without scarring. An excess of metalloproteinases, such as collagenases, may also play a role in scar information. One study showed that nonscarring patients developed peak inflammation 48 h after an acneiform lesion had arisen. Patients with acne scars developed an inflammatory response later in the acne lesion’s evolution and the inflammation was slower to resolve.
Patient History and clinical Examination
Evaluation of a patient with truncal acne scarring requires consideration of several issues.
- The age of the scars should be determined since scars continue to evolve over 12 months and some treatment modalities work best for newer scars.
- The distribution of the scars should be noted as certain
- Acne scar morphology
- Previous use of isotretinoin
Facial acne scars have been classified into three primary morphologic types : icepick, boxcar, and rolling scars. While these scar morphologies can also be seen on the trunk, acne scars on the chest and back are usually either i) hypertrophic /Keloidal ii) atrophic
Some therapies may be directed to both types of scarring, while other therapies are specific to either hypertrophic / Keloidal scars or atrophic scars.
Therapeutic Considerations and Application
Best treatment for scars on the trunk is prevention. Patients who delay starting antiacne medication for at least 3 years from acne onset, have a greater degree of scarring than those who start acne treatment earlier. Isotretinoin therapy is the only proven cure of acne in the course of severe acne in order to prevent scarring.
If scarring does occur, either type of acne scars of the trunk may be treated by surgical excision. Given the high tension of truncal skin, patients should be warned of the high likelihood that the surgical scar might expand or become hypertrophic resulting in a sub-optimal cosmetic outcome. Surgical excision should be contemplated on the trunk only when the surgeon think that the replacement scar will be preferable to the original scar.
Pulsed Dye Laser
Both atrophic and hypertrophic/Keloidal scars may have a red color, especially early in their evolution, due to microvasculature in the scar. The use of the 585 nm pulsed dye laser to lessen scar erythema was first recognized in 1993. Several studies thereafter have confirmed these results and also demonstrated that increasing benefit can be seen with multiple treatments.
The use of ablative lasers for improving acne scarring on the trunk is limited. Ablative systems that are helpful in improving acne scars on the face are not suitable for use on the chest and back. However, new fractional ablative technologies, such as Active FX, Fraxel re:pair(10,600 nm CO2) are being used by some to treat truncal acne scarring without prolonged healing.
Nonablative systems, such as the fractionated 1,550 nm erbium -doped fiber laser can be safely used off the face. The Fraxel laser induces collagenesis underneath atrophic scars. Multiple treatments are needed to treat atrophic scars, and patients are counseled that about 50% improvements in scars can be seen after several treatments.
Other nonablative lasers in infrared range, such as 1,320 nm also can help to improve atrophic scars. These lasers work by causing thermal injury in the dermis while sparring the epidermis with cooling. The infrared lasers are absorbed by dermal water, and the scattering of thermal energy damages dermal collagen, incites an inflammatory response that activates fibroblasts and stimulates collagen remodelling. Multiple treatments are needed to elevate facial atrophic scars with these laser treatments. These devices have minimal efficacy for acne scars on the trunk.
Individual hypertrophic and Keloidal scars may be treated with intralesional corticosteroids to soften and shrink scars as well as to decrease associated pruritus require multiple treatments.