Treatment Of Acne Scarring

Despite the advent of isotretinoin more than 20 years ago, many patients still present with acne scarring. Because of recent technologic advances and the development of creative techniques by today's cosmetic surgeons, there has never been more hope or options for these patients. This article is designed to inform primary care clinicians about the advances that have been made in the treatment of acne scarring, so that they can better advice patients and provide appropriate referrals. It will begin by reviewing the types of acne scarring patients may have and highlighting important considerations, such as the patient's skin type.

The article will then summarize the different procedures that can be offered to patients: dermabrasion; microdermabrasion; laser resurfacing; chemical peeling; subcision; soft tissue augmentation; suture-assisted resurfacing; and punch elevation, punch excision, and punch grafting. These techniques require advanced dermatologic surgical skill and full knowledge of their risks and benefits, of which types of acne scars respond best to which modality, and of how different skin types may respond.

SCARRING
Acne is the most common cause of facial scar in the world.1 Patients with acne scars are often frustrated by their attempts to mask their appearance. Makeup may collect around the rim of widened "saucerlike" indentations and actually make the scars more noticeable. The technique of scar correction will be dictated by the type(s) of scarring present and the patient profile.
The three main types of acne scars are:
-Indented, relatively deep "ice-pick" scars.
-"Broad-based," atrophic, distended scars.
-Thickened, elevated, or "cord-like" hypertrophic scars.
A patient may have multiple types of acne scars that require various treatment modalities.
Before a cosmetic procedure, the clinician and patient must consider:
- How much recovery time the patient can afford with regard to work and home responsibilities.
-The patient's ability to comply with postoperative instructions.
- Whether the patient can avoid sun exposure in order to minimize the risk of post-inflammatory pigment alterations.

The number of scars is also important. For example, a few atrophic scars may be treated with a localninjectable filler substance, whereas a large area of scarring may require a more invasive resurfacing procedure. Additional considerations include the patient's budget, expectations, and Fitzpatrick skin type. Patients with Fitzpatrick skin types IV, V, and VI (typically,
Asians, Hispanics, and blacks, respectively) may not be good candidates for certain resurfacing procedures, given the risk of postinflammatory hyperpigmentation.
It cannot be overstated that the patient and clinician must have realistic expectations when considering scar correction techniques. Because of acne scarring, a patient may have been suffering for many years and may often feel tormented, self-conscious, or depressed, or may even be more seriously disturbed.
These powerful emotions can result in low self-esteem and unrealistic hopes for the procedure. Any corrective procedure helps acne scarring, but it does not give the patient perfectly smooth skin.