Acne scar type determines treatment approach

MIAMI BEACH – Do you cringe when a patient comes in wanting treatment for acne scars? Fear not; such patients are usually very motivated, and effective treatment options exist, according to Dr. Gary Monheit.

It’s true that you can’t perfect their skin, that there is a need to deal with the psychology of what their scarring has meant for them, and that it may take a significant amount of time to temper expectations, he said at the South Beach Symposium.

“But once you win them over, they can be some of the most grateful patients you have. … Don’t turn them away,” he said.

There’s not a lot of training available for treating acne scars, but using existing skill, good judgment, and a combination of tools and techniques can lead to excellent results, said Dr. Monheit, who is in private practice in Birmingham, Ala.

Leveling patient expectations comes down to educating patients about the different kinds of scars and the fact that each type requires different tools.

For example, fillers can be useful – but only for distensible scars. If the scar rises up when the skin is stretched, that’s a distensible scar that will respond to a filler, he explained.

Conversely, if injectable fillers are used in scars with bands that hold them down in deeper tissue, the filler will migrate, surround the scar, and exaggerate its appearance.

A classification system described by Dr. Greg Goodman (Int. J. Dermatol. 2011;50:1179-94]) is useful for determining the best treatment approach based on scar type, he said.

Dr. Goodman described level 1 scars as flat with red, white, or brown marks. Level 2 scars are mild scars visible primarily at close distance, such as while looking in the mirror. Level 3 scars are visible at a conversational distance, but are distensible. Level 4 scars are more severe and are nondistensible.

Peels, cosmeceuticals, and light resurfacing techniques such as the V-beam laser or intense pulsed light, are best for mild scars like level 1 scars, as they typically are erythematous and involve color change, Dr. Monheit said.

For hyperpigmented level 1 scars, consider using topical treatments such as salicylic acid or bleaching agents. For hypopigmented scars, there is a need to blend skin color.

The main thing with these types of scars is to address the color and texture, he said.

Level 2 scars are atrophic, and involve textural and color change. Other resurfacing techniques, including deeper peels, dermabrasion, and laser resurfacing such as with a fractional laser or an ablative laser are particularly useful for these, he said, noting that the treatments can be combined as necessary to achieve the desired results.

Dermarolling also can be helpful for deeper scars.

“As you get into the dermis and deeper, you are breaking collagen bonds and letting skin rise to the surface, and you can also use [dermarolling] as a conduit for whatever you are doing,” he explained.

Needling is another approach that is relatively safe, inexpensive, and involves minimal down time. However, the treatment can be bloody and painful with the depths typically needed for treating scars, he noted.

Moderate scars that are distensible, like level 3 scars, generally need lifting. Fillers are good for these types of scars, and often there is very little more that needs to be done.

Nondistensible scars that are more severe typically require a combination approach. One of the best tools for these types of scars is subcision to loosen them, which creates a pocket that then can be either allowed to fill with blood to raise the scar up or treated with an injectable filler. This is followed by resurfacing to smooth the surface of the skin.

Dr. Monheit described one patient in whom he subcised the nondistensible scars and injected a very small amount – just enough for a surface lift – of Radiesse filler. Significant improvement was seen after two treatment sessions, and then resurfacing was performed.

In another patient with nondistensible scars, he excised a little bit of skin at the scar and performed what amounted to a collagen graft by “chopping it into little pieces – making little pellets – and essentially stuffing those pellets into the pockets with a tiny little needle, giving it lift and stability.” This was followed by resurfacing.

“It really does give a nice result,” he said, noting that subcision may cause some red bumps at first, but these will settle down and the scar will smooth out.

A different approach is needed for other types of scars, such as ice pick scars.

One approach is to punch out the scar surgically and either float the scar up or put a little punch graft in, he said.

Another approach that he uses for ice pick scars is to lightly apply 90% trichloroacetic acid to the base of the scar with a toothpick. This causes an inflammatory reaction that destroys the scar and raises it up, making it distensible and resurfaceable, he said.

Ice pick scars, as well as boxcar scars, divot scars, and hypertrophic scars, need to be refined during the treatment process.

Also keep in mind that patients lose volume as they age, which can cause acne scars to become more prominent. Sometimes a patient will come in with old scars that never bothered them before, and suddenly the scars are much more visible.

“If you volume-fill the face, you’ll improve the scars,” he said, describing one 48-year-old woman who was treated successfully with three sessions of Sculptra, topped off with a little bit of Radiesse.

Dr. Monheit has consulted or performed contracted research for Allergan, Contura, Dermik Laboratories, Galderma Laboratories, Ipsen/Medicis, Kythera Biopharmaceuticals, MELA Sciences, Merz Pharmaceuticals, MyoScience, and Revance Therapeutics.

MIAMI BEACH – Do you cringe when a patient comes in wanting treatment for acne scars? Fear not; such patients are usually very motivated, and effective treatment options exist, according to Dr. Gary Monheit.

It’s true that you can’t perfect their skin, that there is a need to deal with the psychology of what their scarring has meant for them, and that it may take a significant amount of time to temper expectations, he said at the South Beach Symposium.

“But once you win them over, they can be some of the most grateful patients you have. … Don’t turn them away,” he said.

There’s not a lot of training available for treating acne scars, but using existing skill, good judgment, and a combination of tools and techniques can lead to excellent results, said Dr. Monheit, who is in private practice in Birmingham, Ala.

Leveling patient expectations comes down to educating patients about the different kinds of scars and the fact that each type requires different tools.

For example, fillers can be useful – but only for distensible scars. If the scar rises up when the skin is stretched, that’s a distensible scar that will respond to a filler, he explained.

Conversely, if injectable fillers are used in scars with bands that hold them down in deeper tissue, the filler will migrate, surround the scar, and exaggerate its appearance.

A classification system described by Dr. Greg Goodman (Int. J. Dermatol. 2011;50:1179-94]) is useful for determining the best treatment approach based on scar type, he said.

Dr. Goodman described level 1 scars as flat with red, white, or brown marks. Level 2 scars are mild scars visible primarily at close distance, such as while looking in the mirror. Level 3 scars are visible at a conversational distance, but are distensible. Level 4 scars are more severe and are nondistensible.

Peels, cosmeceuticals, and light resurfacing techniques such as the V-beam laser or intense pulsed light, are best for mild scars like level 1 scars, as they typically are erythematous and involve color change, Dr. Monheit said.

For hyperpigmented level 1 scars, consider using topical treatments such as salicylic acid or bleaching agents. For hypopigmented scars, there is a need to blend skin color.

The main thing with these types of scars is to address the color and texture, he said.

Level 2 scars are atrophic, and involve textural and color change. Other resurfacing techniques, including deeper peels, dermabrasion, and laser resurfacing such as with a fractional laser or an ablative laser are particularly useful for these, he said, noting that the treatments can be combined as necessary to achieve the desired results.

Dermarolling also can be helpful for deeper scars.

“As you get into the dermis and deeper, you are breaking collagen bonds and letting skin rise to the surface, and you can also use [dermarolling] as a conduit for whatever you are doing,” he explained.

Needling is another approach that is relatively safe, inexpensive, and involves minimal down time. However, the treatment can be bloody and painful with the depths typically needed for treating scars, he noted.

Moderate scars that are distensible, like level 3 scars, generally need lifting. Fillers are good for these types of scars, and often there is very little more that needs to be done.

Nondistensible scars that are more severe typically require a combination approach. One of the best tools for these types of scars is subcision to loosen them, which creates a pocket that then can be either allowed to fill with blood to raise the scar up or treated with an injectable filler. This is followed by resurfacing to smooth the surface of the skin.

Dr. Monheit described one patient in whom he subcised the nondistensible scars and injected a very small amount – just enough for a surface lift – of Radiesse filler. Significant improvement was seen after two treatment sessions, and then resurfacing was performed.

In another patient with nondistensible scars, he excised a little bit of skin at the scar and performed what amounted to a collagen graft by “chopping it into little pieces – making little pellets – and essentially stuffing those pellets into the pockets with a tiny little needle, giving it lift and stability.” This was followed by resurfacing.

“It really does give a nice result,” he said, noting that subcision may cause some red bumps at first, but these will settle down and the scar will smooth out.

A different approach is needed for other types of scars, such as ice pick scars.

One approach is to punch out the scar surgically and either float the scar up or put a little punch graft in, he said.

Another approach that he uses for ice pick scars is to lightly apply 90% trichloroacetic acid to the base of the scar with a toothpick. This causes an inflammatory reaction that destroys the scar and raises it up, making it distensible and resurfaceable, he said.

Ice pick scars, as well as boxcar scars, divot scars, and hypertrophic scars, need to be refined during the treatment process.

Also keep in mind that patients lose volume as they age, which can cause acne scars to become more prominent. Sometimes a patient will come in with old scars that never bothered them before, and suddenly the scars are much more visible.

“If you volume-fill the face, you’ll improve the scars,” he said, describing one 48-year-old woman who was treated successfully with three sessions of Sculptra, topped off with a little bit of Radiesse.

Dr. Monheit has consulted or performed contracted research for Allergan, Contura, Dermik Laboratories, Galderma Laboratories, Ipsen/Medicis, Kythera Biopharmaceuticals, MELA Sciences, Merz Pharmaceuticals, MyoScience, and Revance Therapeutics.

MIAMI BEACH – Do you cringe when a patient comes in wanting treatment for acne scars? Fear not; such patients are usually very motivated, and effective treatment options exist, according to Dr. Gary Monheit.

It’s true that you can’t perfect their skin, that there is a need to deal with the psychology of what their scarring has meant for them, and that it may take a significant amount of time to temper expectations, he said at the South Beach Symposium.

“But once you win them over, they can be some of the most grateful patients you have. … Don’t turn them away,” he said.

There’s not a lot of training available for treating acne scars, but using existing skill, good judgment, and a combination of tools and techniques can lead to excellent results, said Dr. Monheit, who is in private practice in Birmingham, Ala.

Leveling patient expectations comes down to educating patients about the different kinds of scars and the fact that each type requires different tools.

For example, fillers can be useful – but only for distensible scars. If the scar rises up when the skin is stretched, that’s a distensible scar that will respond to a filler, he explained.

Conversely, if injectable fillers are used in scars with bands that hold them down in deeper tissue, the filler will migrate, surround the scar, and exaggerate its appearance.

A classification system described by Dr. Greg Goodman (Int. J. Dermatol. 2011;50:1179-94]) is useful for determining the best treatment approach based on scar type, he said.

Dr. Goodman described level 1 scars as flat with red, white, or brown marks. Level 2 scars are mild scars visible primarily at close distance, such as while looking in the mirror. Level 3 scars are visible at a conversational distance, but are distensible. Level 4 scars are more severe and are nondistensible.

Peels, cosmeceuticals, and light resurfacing techniques such as the V-beam laser or intense pulsed light, are best for mild scars like level 1 scars, as they typically are erythematous and involve color change, Dr. Monheit said.

For hyperpigmented level 1 scars, consider using topical treatments such as salicylic acid or bleaching agents. For hypopigmented scars, there is a need to blend skin color.

The main thing with these types of scars is to address the color and texture, he said.

Level 2 scars are atrophic, and involve textural and color change. Other resurfacing techniques, including deeper peels, dermabrasion, and laser resurfacing such as with a fractional laser or an ablative laser are particularly useful for these, he said, noting that the treatments can be combined as necessary to achieve the desired results.

Dermarolling also can be helpful for deeper scars.

“As you get into the dermis and deeper, you are breaking collagen bonds and letting skin rise to the surface, and you can also use [dermarolling] as a conduit for whatever you are doing,” he explained.

Needling is another approach that is relatively safe, inexpensive, and involves minimal down time. However, the treatment can be bloody and painful with the depths typically needed for treating scars, he noted.

Moderate scars that are distensible, like level 3 scars, generally need lifting. Fillers are good for these types of scars, and often there is very little more that needs to be done.

Nondistensible scars that are more severe typically require a combination approach. One of the best tools for these types of scars is subcision to loosen them, which creates a pocket that then can be either allowed to fill with blood to raise the scar up or treated with an injectable filler. This is followed by resurfacing to smooth the surface of the skin.

Dr. Monheit described one patient in whom he subcised the nondistensible scars and injected a very small amount – just enough for a surface lift – of Radiesse filler. Significant improvement was seen after two treatment sessions, and then resurfacing was performed.

In another patient with nondistensible scars, he excised a little bit of skin at the scar and performed what amounted to a collagen graft by “chopping it into little pieces – making little pellets – and essentially stuffing those pellets into the pockets with a tiny little needle, giving it lift and stability.” This was followed by resurfacing.

“It really does give a nice result,” he said, noting that subcision may cause some red bumps at first, but these will settle down and the scar will smooth out.

A different approach is needed for other types of scars, such as ice pick scars.

One approach is to punch out the scar surgically and either float the scar up or put a little punch graft in, he said.

Another approach that he uses for ice pick scars is to lightly apply 90% trichloroacetic acid to the base of the scar with a toothpick. This causes an inflammatory reaction that destroys the scar and raises it up, making it distensible and resurfaceable, he said.

Ice pick scars, as well as boxcar scars, divot scars, and hypertrophic scars, need to be refined during the treatment process.

Also keep in mind that patients lose volume as they age, which can cause acne scars to become more prominent. Sometimes a patient will come in with old scars that never bothered them before, and suddenly the scars are much more visible.

“If you volume-fill the face, you’ll improve the scars,” he said, describing one 48-year-old woman who was treated successfully with three sessions of Sculptra, topped off with a little bit of Radiesse.

Dr. Monheit has consulted or performed contracted research for Allergan, Contura, Dermik Laboratories, Galderma Laboratories, Ipsen/Medicis, Kythera Biopharmaceuticals, MELA Sciences, Merz Pharmaceuticals, MyoScience, and Revance Therapeutics.