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The road to acne scar revision

Cystic acne is the main culprit of acne scars, because it creates a bag of pus within the skin. When the pus resolves, the hollow space it leaves behind forms a crater on the skin. When one has cystic acne flares, acne scarring ensues.

There are numerous modalities that can improve acne scars and large pore size. As dermatologists, we follow guidelines as to what modality to use to treat a certain type of scar. But we must also remember that the results of same treatment may vary from person to person. 🧐

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Battle of the needles: microneedling vs. fractional RF needling

subcision + microneedling + fractional RF needling + LED light

Microneedling has been around for ages. It started with the dermaroller and evolved into the automated derma pen. The principle of these devices was to create minute channels on the skin for product infusion and collagen induction.

Recently, the fractional radio frequency needling phenomenon has been making waves in the industry. Its basic principle is quite similar to the manual microneedling device, but with a bonus! The tip of the insulated needles radiate heat which stimulates collagen production even further!!!

I have been using my automated derma pen for years! I combine it with different serums, my favourites are vitamin C and PRP, to boost the effect. I use a variety of depths depending on the facial area and the indication. It is quite a bloody procedure, hence the popular treatment name “vampire facial.”

While I love the how microneedling improves acne scars, I must say that fractional RF needling is microneedling on steroids!!! One fractional RF needling treatment is “like doing three manual microneedling sessions,” according to my patient. Also, the procedure is less bloody than using the manual microneedling device. I can infuse peptides or PRP and add LED light therapy during one treatment session.

The only downside that I find with the fractional RF needling is that patients have a risk of developing scabs and hyperpigmentation post-treatment. NOT ALL patients develop this, but it is a risk especially for darker skinned individuals.

fractional RF needling
fractional RF needling

Scabs develop within 3 to 5 days after the treatment, and fall off within 7 to 10 days.

 

fractional RF needling
fractional RF needling

Here, you can see that there are hyperpigmented grid marks 3 weeks post treatment. Individuals with darker skin color, those who develop long standing dark marks after acne and those who are exposed to a lot of heat and sun light are more prone to develop post-inflammatory hyperpigmentation (PIH). Do not worry though, because PIH will resolve with the help of lightening agents and sun protection.

As you can see from the first 2 photos, adding fractional RF needling to the acne scar revision plan, improves acne scars faster than just using conventional manual microneedling device.

In my practice, I do a combination of treatments to improve acne scars. If you do see me, do not be surprised as I almost always begin treatment with subcision and/or PRP filler/buffer. I find that when you first treat the acne scars under the skin; there will be better result when you eventually do chemical peel, energy-based devices and/or lasers.

Acne scar revision is not a one-time treatment. Your board-certified dermatologist will make a custom treatment plan for you… and this plan will involve a variety of treatments, several sittings and a lot of patience. You’ll get there 🙂

 

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CROSS my scars

TCA CROSS or chemical reconstruction of skin scars (CROSS) using trichloroacetic acid (TCA) is technique that allows focal treatment of acne scars. Ice pick scars and boxcars are ideal lesions for this procedure. A very high concentration of TCA solution is applied precisely on the scars using a sharp wooden toothpick or a syringe to induce inflammation and collagen production of these deep acne scars. A white frost will develop on the affected areas within 10 to 15 seconds, and burning sensation will be felt by the patient. After a 3 to 5 days, scabs will form. These crusts will fall off in 7 to 10 days revealing a shallower scar. Several treatment sessions may be required depending on the severity of the condition.

In my practice, I combine TCA CROSS with other procedures to hasten improvement. But, compared to other procedures, I only do TCA CROSS every 6 to 8 weeks. I prefer to give the skin time to adequately heal. I find that if I do TCA CROSS within a short interval, the skin will improve depth-wise, but will develop hyperpigmentation. :-O

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Cutting Ties

No, I’m not talking about relationships; rather, I’m talking about one of my favorite treatments for acne scars — SUBCISION.

Before we go into the treatment, let’s talk about why we get acne scars. Acne scarring can be in the form of pigmentation, textural changes or both. Pigmentation is quite easy to remedy. The darkened skin color will eventually lighten to normal skin color by itself or with the help of lightening products. On the other hand, textural changes such as ice pick scars, box scars, rolling scars and atrophic scars stay with you throughout your life. We get depressed scars because when have a pimple the pus in the hair follicle disrupts the skin. So when the skin heals, there is a hallowing in the area where the pus used to be and fibrous adhesions to the upper layer of the skin. This is what we see as depressed scars.

Subcision is a minor surgical procedure that cuts the fibrous adhesions that pull the scars down. After the area is anesthetized, a needle is inserted under the skin to release the fibers. You will hear and feel the a “cruck cruck cruck” sensation as the needle cuts through the fibers. It can be quite bloody and bruising is to be expected after the treatment. In our office, we place the patient under LED light to hasten healing after subcision.

In our Acne Scar Revision Program, I almost always do subcision as a first treatment on patients with box scars and rolling scars. Because the anchoring fibers have been cut to release the skin, the depressions improve faster especially after microneedling or other procedures. 🙂