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Treatments for Acne Scar Removal

Updated: Apr 23, 2021

Atrophic acne scar: A result of collagen destruction

Acne scars are caused by abnormal production and degradation of collagen in the course of the healing process, and result in several types of acne scars. In 80 to 90 percent of cases, there is a net destruction of collagen in the skin that results in an atrophic kind of injury but less frequently, there is a net increase of collagen that results in a raised scar or keloid scars.

Type of atrophic acne scar

Atrophic scars or indented scars are classified according to the size and depth of collagen destruction; anyway, a different kind of scars is typically seen on the same person, making differentiation difficult.

There are three types of atrophic acne scars.

  1. Icepick scars - approx. 65 percent of an indented scars. These indentations are narrow, generally smaller than 2 millimeters, V-shaped like, and have a sharp margin that expands down to the deeper skin layer. The depth of these lesions makes icepick scars challenging to fix using standard skin resurfacing options.

  2. Boxcar scars approx. 20 percent of indented scars. These scars are more extensive, 1.5-to 4.0 millimeters, oval-to-round depressions with sharply bound steep edges. Shallow boxcar scars (0.1–0.5mm) are manageable to skin resurfacing treatments, although deep boxcar scars (≥0.5mm) are challenging to treat.

  3. Rolling scars approx. 15 percent of indented scars. These scars are the widest and may reach up to 5mm in diameter. Fibrous adhesion of the skin and the underlying structure results in superficial shadowing and an undulating appearance of the scars.

Examples of icepick, boxcar and rolling acne scars
A) Icepick scars B) Boxcar scars C) Rolling scars

Acne scar treatment at Revival Clinic Bangkok

Since acne scaring usually involves a mixture of scar types, the most effective treatment strategy is multi-modality treatment to answer all types of acne scars. Here is the list of procedures that we use here at Revival Clinic Bangkok.

Ice prick scar treatment via TCA cross

TCA cross is short for “Trichloroacetic acid chemical reconstruction of skin scars” is a technique using high concentrations of acid (TCA) focally on indented acne scars to induce inflammation followed by new collagen production. This can lead to a decrease in the dept of scars and improve cosmetic appearance.

The CROSS technique was the first report by Lee and colleagues. In this technique, a high concentration of trichloroacetic acid is registered focally, by pressing a toothpick-like applicator on the entire indented area of the ice pick scar. Producing a frosted appearance on each scar. Healing is more rapid and related with a low chance of complication rate as the adjacent skin structures are spared.

100% TCA is made to order. We start with a facial cleansing using water and soap to remove oil from the skin. All the ice pick acne scars were marked. Apply the bottom of the injury with 100%. The skin was observed until a ‘frosted’ appearance was seen. The frosting is a result of the protein denature, which is the start of inflammation triggering the new collagen production process. The pain and uncomfortable from this procedure are so minute so no numbness cream or any local anesthesia needed. You may experience mild burning, which was well-tolerated. This was accompanied by frosting, redness and edema, which reduce in 4-6 hours. Crust formation was shown on the next day, which gradually falls off within 3-4 days in most patients depending on their skin type.

A sunscreen should strictly use until all crust falls off to prevent post-inflammatory hyper-pigmentation. Makeup can be applied as usual.

TCA cross result at revival clinic Bangkok.

Eighty percent of our customers show excellent improvement after four sessions and there have never been any severe side effects shown. At the three-month follow-up, the ice prick scar continued to show improvement.

Scar resurfacing treatment by micro-needle

Skin needling, or collagen induction therapy, is known safe and effective for acne scar treatment by skin resurfacing technique. Not only treat the indented scar but also decrease dark spots from acne. Skin needling is a simple, effective and safe way to manage the indented scar. It did not damage the skin, has short recovery time and creates more skin quality. Skin needling also releases fibrous strands to improve indented cutaneous scars and wrinkles.

This method is also useful for skin tightening, rejuvenation and, of course, scar remodeling through improvements in dermal extracellular matrix proteins without causing damage to the epidermis, thus minimizing downtime and limiting side effects.

At revival Clinic Bangkok we use sterilized micro-needles to puncture skin superficially, resulting in new collagen production through activating an inflammatory process. Skin micro-needling induces wound healing, in which collagen is formed underneath the skin over 12 to 18 months in the remodeling process.

Results of micro-needling treatment for acne scars.

There was an outstanding improvement from 400% up to 1000% in collagen and elastin production six months after resurfacing treatment. One year after the therapy, epidermal thickness improves by 40%. The measurement by facial skin analysis showed that the skin roughness had improved one month after treatment.

Acne scar resurfacing by fractional laser

Laser resurfacing, which eliminates the outer layer of the skin to enhance skin regeneration, has been in use since the mid-1990s. Laser resurfacing also has the effect of heat to improve skin regeneration along with elasticity.

Perfectra laser is the latest generation of carbon dioxide fractional lasers, with the combined effects of CO2 laser and fractional technology. A micro-ablative dot of the laser penetrates deep into the skin. Thus severe skin damage is avoided, while lateral thermal damage is decreased, thus reducing downtime and the chances of side effects.

Perfectra lasers have a double effect – they encourage renewable processes of the wound and new collagen production as the hyaluronic acid.

The results of fractional laser treatment in acne scars are fast and practical. Depending on the scar condition and skin type, it significantly improves the look. About 35% of customers there is a complete removal of scarring and, in another 40%, a significant improvement of scars with nearly all showing a decrease of the lesions. Dotted ice prick and indented scars showed the best response to treatment with fractional laser. Fractional photo thermolysis using fractional perfecta laser is a safe and effective method for treating acne scars.

Subcision treatment for acne scar

Subcision is a procedure that removes the adhesion tissue, resulting in scar improvement. Furthermore, the induced scar trauma results in blood clot accumulation and new collagen production, which additionally increase scar elevation. Wider, deeper, and more noticeable rolling scars look dramatically better after subcision treatment than they were initially, although boxcar scars improve much less than rolling scars, the procedure is still useful to some degree. Moreover, subcision has shown increased efficiency when used synergistically with other treatment modalities, such as fractional CO2 laser, platelet-rich plasma (PRP).

Our clinic treatment produced impressive results in patients with severe acne scar grades 4 and 3. Overall improvement was more than 90 percent of the customer (at least one degree of acne scar improvement) with minimal side effects such as slight redness, edema, and pain lasting for 1-2 weeks. Overall, seventy percent of patients showed an excellent response to the treatment and the procedure was well-tolerated by all customers.

Self-extracted growth factor treatment for acne scar

The self-extracted growth factor contains the plasma portion of high platelet concentration. Platelets release growth factors and also platelet-derived growth factor plus transforming growth factor-β, facilitating and accelerating soft tissue regeneration. With its regenerative properties, the self-extracted growth factor enhances the response of acne scars to resurfacing treatment and decrease the post-procedure side effects.

Multiple mechanisms can explain the synergistic effects of self-extract growth factors on overall clinical improvement.

  1. Activated platelets that contain secretory proteins (e.g., platelet-derived growth factor and transforming growth factor) which facilitate chemotaxis and mitogenesis of stem cells, blood vessel formation, and collagen production.

  2. The production of hyaluronic acid which can absorb water, increasing skin volume and elasticity, enhance cell regeneration, extracellular matrix, and collagen production.

Aftercare for acne scar treatment

  • Use at least 2 grams of sunscreen SPF 30 PA+++ apply several times a day and avoid intense sun exposure directly to prevent post-inflammatory hyperpigmentation.

  • Where possible. Avoid intense sun exposure such as sunbathing for at least one month after treatment. If sun exposure is necessary, wear clothing that covers the treated area.

  • Apply sensitive skin moisturizer (no whitening, No perfume, no AHA, BHA) several times a day for a week. This will enhance skin cell regeneration and minimizing the scab from resurfacing treatment.

  • Do not use abrasive scrubs or toners for a week or so after the last treatment. Allow the skin to fully heal

  • before returning to regular skincare routines. Please read the labels. If your products have any glycolic acids or Retinoic acid in them, discontinue use for two weeks before the procedure and two weeks after the procedure.

  • Cleanse and moisturize daily, with light and mild products.

  • If you have a history of cold sores, please inform your doctor.

  • If you have any questions about aftercare management, please let us know. We are always ready to answer any questions so you can get the best result.

Common question and answer about acne scar treatment at Revival Clinic Bangkok

My scars are quite severe, but I saw you offered many techniques for correction. I want to get an idea of what would be the recommended procedures?

Generally, we use multi-modality in each session (TCA cross, PRP, subcision, fractional laser, micro-needling).

This plan works best because the different treatments will take care of all types of scarring; of course, the details of your treatment will depend upon your skin examination.

We can discuss the details more during a face to face consultation. Keep in mind there is no obligation or consultation fee.

I have resistant acne scarring, what would be the best plan for treatment.

The best way in my opinion is

First session

  • TCA cross - to correct pitted scar

  • PRP subcision - self-extracted growth factor help stimulate new collagen production

  • Revival Peel - improve shallow acne scar

  • Miracle mask - a decrease inflammation and downtime from the treatment

Second session

  • Micro-needling - resurface the whole area make the skin even and smooth

  • fractional laser - for deep pitted scar

  • PRP subcision - self-extracted growth factor help stimulate new collagen production

  • Miracle mask - a decrease inflammation and downtime from the treatment

These procedures would be alternated once a month until the desired results are achieved.

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