Atrophic or depressed scars
Atrophic scars form as a result of deficient collagen production following an intracutaneous inflammation. Underlying pathologies such as acne, chicken pox, hesitation cuts, burns, and stretch marks may lead to severe atrophic scars and contour defects in the skin. Atrophic scars may be managed by a variety of treatment options and many times are best managed by combining different therapeutic options.
Assessment, Counseling & Expected Outcome
Counseling involves a detailed evaluation of the patient’s mental condition, motivation for treatment, treatment expectations and financial situation. Counseling also entails a discussion of the surgical and non-surgical management options available to people. Post treatment outcomes are usually satisfactory but complete correction may not be possible in every person. Many patients benefit from a multi treatment approach and must realize that the optimum outcome will take time to the end result.
Resurfacing and Tightening
1 - Microdermabrasion
Microdermabrasion (MDA) is a minimally invasive technique that improves very superficial scars, open pores and skin texture. Microdermabrasion involves a skin care specialist removing the top layer of skin with a small hand-held device. Microdermabrasion can exfoliate the skin, reduce signs of aging, make the skin appear more even, and, over time, improve some atrophic or depressed scarring of the skin. The procedure is safe with any skin color.
2 - Chemical Peels
- Chemical peels play a crucial role in the management of all atrophic scars due to their low cost of treatment and versatility.
- Hydroxy acids may be used to treat all types of acne scars in addition to reducing post inflammatory redness and hyperpigmentation
- Salicylic acid 30 % in multiple sessions with an interval of 4-6 weeks is effective in treating superficial acne scars.
- Mandelic acid 10% in combination with Salicylic acid 20% or 35 % glycolic acid peel are useful in the treatment of atrophic scarring. Glycolic acid peels combined with microneedling have been shown to be effective in the treatment of acne scars.
- Lactic acid has been shown to lighten pigmented scars.
- Jessners solution alone or combined with trichloroacetic acid 20% may be useful in acne scars.
- 40-70% Pyruvic acid is effective in the management of moderate acne scars.
- Trichloroacetic acid (TCA), depending on its concentration is the most versatile and potent peeling agent for treating acne scars. TCA can be used as a superficial, medium or deep peel. TCA 20 % and TCA 20% + Modified Jessners solution have both been evaluated and shown to be effective in the treatment of acne scars. TCA 20% combined with percutaneous collagen induction is useful in the management of atrophic acne scars.
- Superficial peels like full strength 92% Lactic acid, Jessners solution, 20-70 % Glycolic acid, 10-25 % TCA are safe and multiple sessions can ameliorate superficial acne scars. Extra caution needs to be exercised with moderate depth (25-50% TCA or TCA 35% + Jessners solution ) peels in view of the risk of PIH and post treatment scarring.
- TCA CROSS technique is the application of 50-100% TCA over scarred areas and is used to improve deep ice pick acne scars
3 - Microneedling
The improvement in acne scars through microneedling is based on the principle of percutaneous collagen induction. The technique is performed under topical anesthesia and involves puncturing the skin with fine miniature needles by using a drum shaped device called a dermal roller or a dermaroller. The standard dermaroller with 192 needles is rolled over the skin 15-20 times in horizontal, vertical and oblique directions. Reduction occurs in scars as the procedure triggers release of growth factors leading to new collagen formation. Newer modifications of the dermaroller include Dermastamp (effective on localized individual scars) and Dermapen which has a detachable head consisting of 12 microneedles that can penetrate to variable depths in the skin. Microneedling is effective in all types of atrophic scars but most effective on rolling scars. Other brand names for popular dermarollers include SkinPen, Collagen PIN, and Stratapen.
4 - Lasers
Lasers in scars are based predominantly on the fractional technology which works on the principle of fractional photo thermolysis. Fractional lasers create microscopic thermal zones of controlled depth and density around which normal skin acts as a reservoir of tissue repair, leading to faster and more predictable healing times as compared to fully ablative laser resurfacing.
(A) - Ablative fractional lasers (AFL)
Commonly used ablative fractional lasers are 10,600 nm CO2 laser and 2940 nm fractional erbium YAG laser. Fractional 10,600 nm CO2 laser is commonly used and widely studied in the treatment of atrophic scarring.
(B) - Non ablative fractional lasers (NAFR)
NAFR use laser sources like erbium or thulium in the mid infra-red wavelengths such as 1550nm, 1440nm, and 1927nm to treat scarring conditions. Fractional 1540 erbium glass, Fractional 1,550nm Erbium-doped laser (EDL) have shown good results in acne scars. These lasers are safe in dark skin but require multiple sessions for a good therapeutic outcome. A new NAFR 1565 nm has been introduced which shows promise in acne scars and other depressed scars.
(C) - Other Lasers
Other lasers such as 1064-nm Nd: YAG laser, Pulsed dye laser (PDL), Intense pulsed light (IPL), and picosecond lasers are effectively used in treating pigmented and red scars.
5 - Microneedle Fractional Radiofrequency
Microneedle radiofrequency fractional (MNRF) delivers bipolar radiofrequency to the dermis via an electronically smooth controlled insertion pins which have minimal penetration into the upper portions of the dermis as well as needles which may be non-insulated or insulated microneedles. Microneedles also cause a mechanical disruption of fibrotic strands and improvement of atrophic scars over time.
MNRF is useful in treating deep acne, chickenpox and other atrophic scars. MNRF usually requires 4-6 sessions and can be used as a first line treatment in people with darker skin color
Dermal Lift Techniques
1 - Punch techniques
(A) - Punch Excision
Punch excision is a technique where an instrument called a punch is used to perform a full thickness excision following which the wound is sutured. Punch excision is preferred for ice pick scars and deep boxcar acne scars.
(B) - Punch Grafting
A graft is placed at the punch excision site but often results in texture and color mismatch
(C) - Punch Elevation
A punch biopsy instrument is used to excise the scar and its walls . after which it is elevated enough to be slightly raised against the bordering tissue. This technique is useful in treatment of deep boxcar scars with sharp edges and normal bases.
2 - Subcision
Subcision is a procedure of releasing fibrotic bands under the skin by inserting a needle under the skin in multiple directions. Subcision is more effective for rolling acne scars and less effective for treating boxcar and ice pick scars
Volume-Imparting Techniques
1 - Dermal Fillers
Hyaluronic Acid Fillers are the most commonly used dermal fillers used around the world Nonanimal, cross-linked hyaluronic acid (NAHA) has been seen to improve soft boxcar or rolling scars following prior release of fibrous bands underneath the skin. Other technologies, including the Vycross fillers and others have been used successfully. Fillers for acne scarring can be utilized in two ways. Fillers can be injected directly beneath scars for immediate improvement. Second, volumizing fillers, such as poly-L lactic acid (PLLA) or calcium hydroxylapatite, can be delivered to areas where there is laxity of skin. Dermal fillers can be divided into permanent (PMMA, polyacrylamide, polyalkylimide), semi-permanent (PLLA, calcium hydroxyapatite) and temporary (hyaluronic acid).
In the United States, PMMA, or BellaFill, does have an FDA clearance to treat atrophic acne scars. The other products mentioned above, have not been FDA cleared but have shown in multiple clinical trials to be effective in the treatment of atrophic scars.
2 - Dermal and Fat Autografting
(A) - Dermal Grafting
This procedure should be performed on atrophic scars at least 4 mm in diameter. Harvested dermis is processed and implanted into recipient areas.
(B) - Autologous fat grafting
Autologous fat grafting is useful in managing lipoatrophic scars, common in the jawline area and lower cheeks. Lipofilling has the advantage of supplying fat tissue-derived stem cells, which have an important role in the regeneration of collagen. Nano fat achieves better outcomes. Fat is harvested either from the lower abdomen or the thigh after anesthesia. Nanofat is injected beneath the dermis to replace lost tissue. The advantages of lipofilling are that it is safe, easy to obtain, feels natural and large amounts can be harvested and with minimal downtime.
Combination Approaches
Combination treatments may provide faster, safer and more efficacious outcomes in severe atrophic scars. Combination of lasers, energy devices with techniques like needling, TCA cross, punch techniques, subcision, scar revision, fat grafting or fillers are much better than single modality treatments. Most commonly combined treatments are fractional radiofrequency with fractional ablative lasers, subcision with fractional lasers, and TCA cross with fractional lasers.
Targeted Approach for Atrophic Scar Management
Icepick Scars | Rolling Scars | Boxcar Scars | Lipoatrophic scars |
|---|---|---|---|
| Subcision combined with microneedling or fractional lasers |
| Subcision followed by soft tissue augmentation with fillers or autologous fat |
Icepick Scars
- Fractional RF
- Microneedling
- TCA Cross
- Fractional lasers
Rolling Scars
Subcision combined with microneedling or fractional lasers
Boxcar Scars
- Superficial: Subcision followed by laser resurfacing, MNRF or microneedling
- Deep: Punch excision
Lipoatrophic scars
Subcision followed by soft tissue augmentation with fillers or autologous fat