When a patient requests treatment for acne scars, it is imperative that any inflammatory lesions of acne present be quickly controlled to prevent further scarring. The patient has to be educated and her co-operation secured to minimize potential scarring from poorly controlled acne in the future.
Patient factors which require consideration when formulating a holistic treatment regimen include: the patient's tolerance of procedure-related risks and 'downtime', the ability of the patient to co-operate with instructions, commitment to the process, Fitzpatrick skin type and tendency for poor wound healing.
A regimen of topical therapy for scar and acne treatment, in the acne-prone, forms the foundation of a scar treatment programme. Topical agents used include gycolic acid, tretinoin and a sunblock, as a bare minimum.
Acne scars may be catergorised according to the morphology into protuberant and depressed scars. Protuberant scars (keloids and hypertrophic scars) are managed by intralesional steroid injections, pulsed dye laser therapy or application of silicone sheets.
In assessing the types of depressed scars present, the distensibility of the scars should first be noted. Depressed acne scars can be classified by morphology into rolling scars, boxcar scars and ice pick scars.
Each type of scars demands different strategies for treatment. The dermatologist needs to be familiar with the various procedures available for acne scar treatment, the results obtainable and limitations.
The procedures commonly employed include chemical peeling, injection of fillers, scar excision, subcision, dermabrasion and laser resurfacing (ablative and non-ablative).
Distensible scars respond to treatment using all the modalities stated while nondistensible, fibrotic scars often require scar excision or subcision, although non-ablative laser resurfacing is helpful in some. It, therefore, makes sense to address the non-fibrotic depressed scars early in the treatment plan.
In summary, the rational management of acne scars calls for coordinated efforts to prevent further scarring due to inflammatory acne, assessment of the type of scars present and the tailoring of a treatment regime that is appropriate for these scars. Management needs to be individualized taking into account such factors as the patient’s lifestyle and tolerance for the risks of the various procedures.