Acne Scarring Acne Scar Treatment and Mediclal Management
J AM ACAD DERMATOL
Table I. Medical management
Various other topical or injectable substances
Some lesions are called ‘‘scars’’ but are not truly so by definition but, rather, are changes in skin color. A first is postinflammatory erythema. The resolving acne site’s initialpresentationmay bepink or red but usually improves. Persistent redness can be addressed with laser or other therapy. Postinflammatory hyperpigmentation is a very commonly seen variant. It is a black or brown residual discoloration in the location of previous acne or other inflammatory reaction.
These lesions are more common in those with darker skin or those who tan. Fading may occur but quite frequently takes a prolonged time period, sometimes up to a year. Chemical peels, lasers, or bleaching agents are usually the first-line therapies. Hypopigmentation is a loss of pigment in the area of the lesion. It can range from lightening to total whitening of the skin. Often these areas do not regain the level of previous pigmentation and only late if so. Multiple treatments can be considered for all of these pigmentary lesions after the acne is adequately addressed. Included are hydroquinone, tretinoin, cortisone, azelaic acid, camouflage, combination creams (primary choice is retinoid plus hydroquinone), superficial chemical peels, microdermabrasion, laser therapy, or ultraviolet A/B sunscreens. 28
The one agreed-on facet is that the most effective treatment for both the true scars and pigmentary changes is to prevent and control the acne lesions themselves to limit inflammation and other sequelae.
ACNE SCAR TREATMENT
Treatment of the true scars resulting from acne must reflect several considerations by the physician. Cost of treatment, severity of lesions, physician goals, patient expectations, side-effect profiles, psychological or emotional effect to the patient, and prevention measures should all play a role. The ultimate goal of any intervention is for improvement, not for a total cure or perfection.
Single treatment, multiple treatments, or combination therapy may be required. An excellent review and discussion by Goodman29 on postacne scarring treatments was recently published as an update to a similar previous study by Goodman and Baron.30 Another in-depth article by Tsau et al31 examined the procedural techniques available. Studies to evaluate these methods are often difficult because of sample sizes, lack of controls, objective grading scales, follow-up, or sponsorship/funding bias.
The following sections, although not totally comprehensive, will attempt to cover a majority of the medical, procedural, and surgical options. It is less often that acne lesions lead to hypertrophic scars or keloids, however, it is a possibility and certainly is a side effect consideration with treatments for other types of scars, so will therefore be included in these discussions. There will be an attempt to mention basic information or pertinent advantages or disadvantages for each of the options from review of literature that is as fairly contemporary as possible.
There are numerous medical options available for treatment of acne scars. Hypertrophic scars, keloids, and pigmentary changes are the usual focus of medical management whereas the other types require other forms of intervention.
Only a few of the more commonly used or proven selections will be mentioned here (Table I). Of course, if desired, more information can be researched for such topicals or injectables as vitamin A, vitamin E, vitamin C, zinc, colchicine, hyaluronidase, cyclosporine, honey, onion extract, 5-fluorouracil, bleomycin, retinoids, verapamil, pepsin, hydrochloric acid, formalin, and almost unlimited others. Retinoids, specifically, have supporting sparse reports of treatment to keloids, hypertrophic scars, and very superficial scars.32 The benefit is attributed to an increase in elasticity with dermal collagen deposition and alignment.33
One of the more popular choices for medical therapy, again, mostly for hypertrophic scars and keloids, is the use of the generically termed ‘‘steroids.’’ These are substances that are based on 4 fused carbon rings that derive from the cholesterol molecule. The glucocorticoids (eg, triamcinolone, hydrocortisone, methylprednisone, and dexamethasone), in the corticosteroid family, have immunomodulatory and anti-inflammatory properties. They reduce the expression of cytokines, cellular adhesion molecules, and other enzymes related to the inflammatory process.34 The exact mechanism is unknown but it is thought to related directly to the anti-inflammatory properties, reduction of collagen, glycosaminoglycans, and fibroblasts, along with overall lesion growth retardation. Used as a topical, both with and without occlusion, there is a wide range of clinical response.
Steroids used in high doses, typically intravenously, may lead to multiple systemic side effects but these are highly unlikely in the topical doses used in scar treatment. However, cutaneous use does include side effects that might include telangiectases, bruising, atrophy, pain, or pigmentary change.
The other route, some say the
first-line treatment, commonly used for hypertrophic scar and keloid treatment is intralesional injection because surgery is often debatable for these lesions. Often, multiple injections spaced one or several months apart are required to determine the final result and prevent excess atrophy. If a permanent filler for augmentation is used and there is overcorrection, atrophy of the area may be a desired effect to balance the contours. Other side effects of injected steroids include intolerance, necrosis, allergy, bruising, hyperpigmentation or hypopigmentation, injection pain, and telangiectases.
Acne Scarring A review and current treatment modalities BACKGROUND and ACNE SCARS ACNE SCARS page 2 ACNE SCAR TREATMENT and MEDICAL MANAGEMENT SURGICAL MANAGEMENT PROCEDURAL MANAGEMENT PROCEDURAL MANAGEMENT page 2 TISSUE AUGMENTATION TISSUE AUGMENTATION page 2 TISSUE AUGMENTATION page 3 TISSUE AUGMENTATION page 4 Light, laser, and energy therapy Light, laser, and energy therapy page 2 Light, laser, and energy therapy page 3 Light, laser, and energy therapy page 4 Conclusion and REFERENCES Manufacturers of brand name drugs mentioned in this article