What are the most effective treatment options for a patient with scarring?

Treatment of Scarring

For atrophic acne scars, microneedling combined with platelet-rich fibrin (PRF) or platelet-rich plasma (PRP) is the most effective treatment, showing 70% mean improvement and significantly superior outcomes compared to single modalities. 1, 2

Atrophic Acne Scars (Ice Pick, Rolling, Boxcar)

First-Line Treatment: Microneedling + PRF/PRP

The combination of microneedling with PRF demonstrates 3-fold higher "excellent" outcome rates compared to PRP, making PRF the preferred platelet concentrate. 1, 2

Treatment protocol:

• Three sessions spaced one month apart 2
• Needle depth: 1.5 mm 2
• Apply PRF/PRP before microneedling (not after) to allow needling to push platelets deeper into dermis 2
• Maintenance every 6 months 2

Expected outcomes by scar type:

• Rolling scars: Best response 2
• Boxcar scars: Good response 2
• Ice pick scars: Most resistant (may require additional punch excision) 2, 3

Clinical efficacy data:

• Microneedling + PRP: 70.43% mean improvement 1, 2
• PRP alone: 48.82% improvement 1, 2
• Microneedling alone: 39.71% improvement 1, 2
• Goodman and Baron scar grade reduction from 3.45 to 1.47 with combined treatment 2

Adjunctive Laser Therapy

Fractional CO2 laser combined with PRP provides synergistic effects with significantly shorter downtime and reduced inflammation compared to laser alone. 1

• Combination treatment shows 75% improvement versus 50% with laser alone 1
• PRP-treated areas demonstrate significantly decreased edema and pain 1
• Erythema, edema, and crusting are significantly less severe on PRP-treated sides 1

Surgical Options for Specific Scar Types

For ice pick scars resistant to microneedling, punch excision followed by healing or suturing is indicated. 3

For rolling scars with tethering, subcutaneous incision (subcision) releases fibrous bands before microneedling treatment. 3

Critical Pitfall to Avoid

Never use Q-switch lasers for atrophic acne scars—they deliver nanosecond pulses at temperatures up to 900°C designed to fragment pigment, not stimulate collagen remodeling needed for scar improvement. 2

Hypertrophic Scars and Keloids

First-Line Treatment: Silicone-Based Products

Silicone gel sheets or silicone gel are the gold standard, first-line, non-invasive option for both prevention and treatment of hypertrophic scars and keloids. 4

• Apply continuously for at least 12 hours daily 4
• Continue for minimum 2-3 months 4
• Silicone gel and sheets show equivalent efficacy 5
• Superior to onion extract products (Contractubex) 5

Second-Line Treatment: Intralesional Corticosteroids

For hypertrophic scars and keloids not responding to silicone, intralesional triamcinolone acetonide 10-40 mg/mL is indicated. 6, 7, 4

FDA-approved indications for intralesional steroids include:

• Keloids 6
• Localized hypertrophic, infiltrated, inflammatory lesions 6
• Psoriatic plaques, lichen planus, granuloma annulare 6

Injection protocol:

• Inject every 4-8 weeks 4
• Use lower concentrations (10 mg/mL) to minimize atrophy risk 1
• Often combined with cryotherapy for enhanced efficacy 7, 4

Combination Therapy Options

For resistant keloids, intralesional 5-fluorouracil combined with corticosteroids shows enhanced efficacy. 7, 4

Cryotherapy combined with intralesional corticosteroids provides synergistic scar flattening. 7, 4

Additional Treatment Modalities

Laser therapy (ablative and non-ablative) may be used for resistant scars, particularly pulsed dye laser for erythema and vascular components. 7, 4

Surgical excision is reserved for large keloids but carries high recurrence risk (45-100%) unless combined with adjuvant therapy such as radiation or intralesional steroids. 4

Prevention of Acne Scarring

Early Aggressive Acne Treatment

Patients with severe nodular acne, psychosocial burden, or any scarring should be considered candidates for isotretinoin to prevent further scarring. 1

Intralesional corticosteroid injections (triamcinolone 10 mg/mL) should be used judiciously for larger acne papules or nodules at risk of scarring for rapid improvement in inflammation. 1

General Preventive Measures

For all healing wounds at risk of scarring:

• Avoid sun exposure (UV radiation worsens scar pigmentation and hypertrophy) 4
• Apply compression therapy when feasible 4
• Use moisturizers to maintain optimal wound hydration 4
• Consider prophylactic silicone gel application for high-risk wounds 4

Re-evaluation Schedule

Re-evaluate all patients undergoing scar treatment every 4-8 weeks to determine if additional or alternative treatment is warranted. 4