Treatment of Pox Scars
Laser resurfacing with high-powered CO2 laser is the most effective treatment for pox scars, achieving excellent or good results in 71% of patients, with sharply demarcated scar margins fading and improved depth and width of depressed scars. 1
Primary Treatment Approach
CO2 laser resurfacing should be the first-line treatment for significant pox scars, using different techniques based on scar morphology 1:
- Even-depth resurfacing for shallow, widespread scarring 1
- Shoulder technique for scars with distinct edges 1
- Laser punch-out method for deep, ice-pick type scars 1
The precision of depth control with laser technology makes it superior to conventional dermabrasion or chemical peeling, which have historically shown poor results for the distinct cobblestone appearance of pox scars 1.
Alternative and Adjunctive Treatments
Chemical Peeling
- Trichloroacetic acid (TCA) peeling is the most frequently used non-laser method, showing moderate to excellent response in post-varicella scars 2
- Can be considered when laser technology is unavailable or cost-prohibitive 2
Combination Approaches
- Sequential treatment with intracision followed by Er:YAG laser (2,940-nm) can enhance results for boxcar-type pox scars 3
- Intracision works by untethering fibrotic strands and raising collagen synthesis, with additional benefit from intradermal blood pocket formation 3
- This combination specifically addresses the vertical edges characteristic of pox scars 3
Other Modalities
For atrophic pox scars, consider 2, 4:
- Microneedling as a less invasive option
- Subcision for tethered scars, though less effective for boxcar-type pox scars 3
- Topical tretinoin for superficial scarring 2
Managing Complications
Hypertrophic Scarring
- Occurs in approximately 9% of laser-treated patients 1
- Treat with intradermal triamcinolone injections, which successfully resolves hypertrophic changes 1
Pigmentary Changes
- Hyperpigmentation occurs in 19.7% of patients but responds well to postoperative skin care 1
- Prolonged erythema affects 7.9% of patients and typically resolves spontaneously 1
Infection Prevention
- If infection develops (painful lesions, pustules, yellow crusts, or discharge), obtain bacterial cultures 5
- For confirmed MRSA, use clindamycin 300-450 mg orally three times daily or TMP-SMX 1-2 DS tablets twice daily 5
- For severe infections, consider IV vancomycin 15-20 mg/kg every 8-12 hours or linezolid 600 mg IV twice daily 5
Critical Pitfalls to Avoid
- Do not use dermabrasion or chemical peeling as first-line treatment for significant pox scars—these methods have poor efficacy compared to laser resurfacing 1
- Avoid treating all scar types with the same laser technique—match the resurfacing method to scar depth and pattern for optimal results 1
- Do not dismiss atypical changes in old pox scars—malignant transformation, though rare, has been documented even decades after initial scarring 6
- Obtain cultures in treatment-resistant cases to avoid prolonged ineffective therapy when bacterial superinfection is present 5
Evidence Quality Considerations
The strongest evidence for pox scar treatment comes from a case series of 76 patients treated with CO2 laser resurfacing, demonstrating consistent improvement with manageable side effects 1. While chemical peeling with TCA is frequently reported in the literature for post-varicella scars, there is insufficient evidence to accurately compare its efficacy to laser modalities 2. The combination approach with intracision and Er:YAG laser represents an emerging technique with promising results for specific scar morphologies 3.