What are the treatment options for acne scars?

Treatment Options for Acne Scars

For patients with acne scars, a multimodal approach combining procedural treatments with medical therapy is recommended based on scar type, with isotretinoin being the most effective treatment for preventing new scarring in patients with active acne. 1, 2

Types of Acne Scars and Assessment

• Acne scars can be classified as atrophic (depressed) or hypertrophic (raised), with atrophic scars being more common 3
• Assessment should include evaluation of scar type, distribution, and psychological impact, as acne with psychosocial burden or scarring warrants more aggressive treatment 2
• The presence of scarring alone should classify the patient as having severe acne, making them a candidate for isotretinoin therapy 2

Medical Treatments for Preventing New Scars

First-Line Treatments

• Oral isotretinoin is strongly recommended for patients with acne scarring to prevent new scar formation and is considered the most effective treatment for patients with moderate-to-severe acne with scarring 1, 2
• Topical retinoids (tretinoin, adapalene, tazarotene, trifarotene) are strongly recommended for both active acne treatment and improvement of mild scarring and post-inflammatory hyperpigmentation 1, 2
• Fixed-dose combination of topical retinoid with benzoyl peroxide is strongly recommended for topical combination therapy 1, 2

Second-Line Treatments

• Systemic antibiotics (doxycycline, minocycline, sarecycline) are recommended for moderate-to-severe acne but must be combined with topical therapy to prevent resistance 1
• For female patients, hormonal therapy with combined oral contraceptives or spironolactone is conditionally recommended 1
• Intralesional corticosteroid injections are recommended as adjuvant therapy for larger inflammatory nodules at risk of scarring 1, 2

Procedural Treatments for Existing Acne Scars

For Atrophic (Depressed) Scars

• Microneedling and radiofrequency microneedling are effective for treating atrophic acne scars by stimulating collagen production 4, 5
• Chemical peels (glycolic acid, salicylic acid) can improve superficial atrophic scars and post-inflammatory hyperpigmentation 1, 5
• Dermal fillers can temporarily improve the appearance of deeper atrophic scars 4, 6
• Punch techniques (punch excision, punch elevation, punch grafting) are effective for treating ice-pick and boxcar scars 4, 6
• Subcision (subcutaneous incisionless surgery) can be used to release fibrous bands that tether down atrophic scars 5, 6

For Hypertrophic and Keloid Scars

• Intralesional corticosteroid injections are effective for reducing keloid and hypertrophic scar formation 6
• Silicone gels or sheets can improve hypertrophic and keloid scars 6, 3
• Cryotherapy can be used for small hypertrophic scars 3

Combination Approaches

• Combining treatments often yields better results than monotherapy for acne scars 4, 5
• Ablative lasers (Er:YAG, CO2) combined with topical agents like silicone gel, growth factors, or platelet-rich plasma show promising results 7
• Microneedling with topical retinoids or growth factors enhances penetration and efficacy 7

Topical Management for Maintenance

• Topical retinoids (tretinoin) should be applied once daily before bedtime to affected areas to help with post-inflammatory hyperpigmentation and mild scarring 8
• Azelaic acid is conditionally recommended for acne treatment and can help with post-inflammatory hyperpigmentation 1
• Proper application technique is essential: wash with mild soap, wait 20-30 minutes before applying medication, and use only a small amount 8

Common Pitfalls to Avoid

• Underestimating severity: The presence of scarring should prompt consideration of isotretinoin even if active lesions appear moderate 2
• Using topical antibiotic monotherapy, which can lead to antibiotic resistance 1
• Expecting immediate results: Tretinoin works deep inside the skin and may take 6-12 weeks to show improvement 8
• Overusing topical medications: Applying more than recommended can cause irritation without improving results 8
• Neglecting psychological impact: Acne scarring can significantly affect quality of life and may require more aggressive treatment 2

Treatment Algorithm

1. For active acne with scarring:

   • Severe or moderate with scarring: Oral isotretinoin 1, 2
   • If isotretinoin contraindicated: Systemic antibiotics plus topical combination therapy 1

2. For existing scars after acne clearance:

   • Atrophic scars: Microneedling, chemical peels, laser therapy, or punch techniques based on scar depth 4, 5
   • Hypertrophic scars: Intralesional corticosteroids, silicone products 6, 3
   • Maintenance: Topical retinoids for ongoing improvement 8, 7

3. For all patients:

   • Assess psychological impact and consider more aggressive treatment if significant 2
   • Maintain consistent treatment regimen for optimal results 8