Updated: Jun 10, 2020
Quick Facts about acne treatment
The causes of acne are multi-factorial and different for each person, and therefore acne treatments used vary from person to person
Acne is a medical problem and not just a cosmetic one
Acne left untreated can lead to permanent scarring
For acne that is resistant to the normal modalities of treatment, oral isotretinoin can be used.
What causes acne?
There are a number of contributors to the formation of acne. Excess oil and sebum production exacerbated by hormonal influences on sebaceous glands, as well as dead skin physically blocking pores can cause acne. A bacterium named Propionibacterium acnes (p.acnes) has also been implicated as a cause of acne. All treatments for acne will address one or more of these issues.
There is also a significant genetic component to acne. A twin study has shown an 81% of the factors causing acne are genetic. Also, the degree of oil or sebum production from the skin is largely inherited.
There have been no studies showing that acne is caused or exacerbated by your diet, contrary to the usual belief that certain foods can worsen acne.
Inappropriate make-up or moisturisers can also be comedogenic, that is block pores and cause blackheads. Finding appropriate skin care and make-up is a key part of treating acne.
A good cleanser is the first step in acne treatment. Usually, it is best to simply use a gentle cleanser. Over cleansing the skin can lead to the skin producing more oil and therefore more acne.
Exfoliants can also help. Exfoliants with beta-hydroxy acids (eg. salicylic acid) have the advantage of having anti-inflammatory properties and are more oil soluble making them penetrate oily skin better than alpha-hydroxy acids. Again, over-exfoliation of the skin can cause irritation and often exacerbation or flare-ups of acne.
Benzoyl peroxide is a good product for reducing active acne lesions and also has anti-inflammatory properties. It is available in varying concentrations. The higher the concentration, the more flaking, and irritation of the skin. Therefore, commencement should be with the lower concentrations. The author personally finds that the skin becomes accustomed to benzoyl peroxide in the long term, and tends to have less effect the longer it is used. Also it is possible to develop a benzoyl peroxide allergy.
Topical retinoids, derivatives of Vitamin A, are also used in the treatment of acne. They remain one of the most effective topical agents in the treatment of acne. Retinoids work by increasing the natural turnover rate of the skin. Therefore, there are less dead skin cells at the surface of the skin and fewer blockages as a result. This property of retinoids also means that skin texture and fine wrinkles also improve. Some retinoids also help to reduce the number of bacteria causing acne in the skin.
Skin can usually appear red, flaky, lumpy, and irritated for up to one month after commencement of retinoids. This is called retinoic dermatitis. Starting slowly is important to reduce these side effects. Sunscreen is also imperative with the use of retinoids as they can initially exacerbate sun sensitivity. Retinoids should not be used in pregnant mothers, those planning to be pregnant, or those who are breast-feeding.
Retinoids come in various forms. Retinoic acid, or tretinoin are examples of retinoids and include prescription-only variants such as Stieve-A, and Retin-A. Retinols are another form of retinoid. PCA also has a range of retinols of varying strength. Although more expensive than their prescription-only variants, they have the added property of being chirally correct. Each molecule has a left and a right-sided version, like a pair of hands. In the case of retinols, the left sided version is more active and less irritating to the skin.
Aspect DR has more of the left sided version of the molecule and is therefore chirally correct. For those who have more sensitive skin, retinaldehyde serum (another version of a retinoid) can be used instead. Retinaldehyde is purported to have fewer of the adverse side effects of other retinoids with the same benefits. Many of the PCA products contain retinaldehyde also. Retinaldehyde has been shown in clinical studies to help reduce the bacteria that cause acne.
Acne scar treatments
There are various types of acne scars, each treated with different methods
Acne scarring treatments need to be matched to the patient’s acne scarring type, skin type, and recovery time permitted.
There are various types of acne scarring, classified based on their severity and morphology.
Treatment of acne scarring on olive or darker skin types carries the risk of post-inflammatory hyperpigmentation. Non-laser treatments carry less risk of this than laser treatments.
Laser treatments include laser resurfacing with the carbon dioxide laser or erbium lasers, or fractional laser treatment like the fractional CO2 lasers.
Non-laser treatments include the skin needling, and TCA CROSS.
Generally multiple treatments are required for the best results, and acne scarring can be improved in most cases but not completely resolve
What type of acne scars are there?
Macular scarring – this type of acne scarring is characterised by flat areas of increased and decreased pigmentation as a result of acne. Although there are not any indentations in the skin or raised scars, this is considered as a scar by many patients who have this problem.
Boxcar scars – these acne scars are superficial punched out scars that have sharp vertical edges on cross section and can be round or oval shaped when seen from above.
Rolling scars – these acne scars appear as undulations in the skin and are usually caused by tethering of the skin to be underlying structures
Deep divots – these are simply very deep scars that involve loss of subcutaneous tissue volume and result in a large divot.
Ice-pick scars – deep but small holes in the skin, similar to the indentation left by an ice-pick.
Hypertrophic scarring – where there is a raised and often pigmented scar as a result of acne.
Keloid scars – where the size of the scar is significantly raised, red/purple, and disproportionate to the size of the initial trauma caused by the acne
What Categories of severity of acne scars are there?
Macular scarring or flat scarring that is characterised by flat areas of increased or decreased pigmentation visible from greater than 50cm.
Mild disease that is visible at distances of less than 50cm and can be covered by make-up. Examples include mild rolling acne scars.
Moderate disease that is visible at 50cm or greater and is not easily covered with make-up or the normal shadow of a shaved beard hair. Stretching the skin can flatten the scar. Examples include more significant rolling scars, shallow boxcar scars, and mild to moderate hypertrophic scars.
Severe disease as in grade 3 but scarring is not flattened by stretching the skin. Examples include severe boxcar scars, deep divots, ice pick scars, and hypertrophic/keloid scarring (very raised/pigmented scars).
Skin care of acne scarring
Acne commonly induces changes to skin pigmentation and skin tone. This occurs particularly on olive or darker skin types affected by acne. Hyperpigmentation can occur after trauma to the skin induced by an acne lesion. The hyperpigmentation that occurs is usually a result of inflammation caused from acne and is called post-inflammatory hyperpigmentation.
Hypopigmentation, or a loss of pigmentation, can also occur as a result of acne, can often be permanent. Redness of the skin is common after an acne lesion has passed.
In many cases, these changes in skin pigmentation tend to resolve themselves with time, once the active acne has subsided. Often patients will want to expedite this process, as natural regression of this problem can often take more than a year. The key priority is to treat any active acne, and often using medical grade skin care can be helpful.
Retinoids, or analogues of vitamin A, can help skin turnover and keratinisation (which can block pores) and reduce acne. Using a non-comedogenic sunscreen can also help to reduce post-acne skin tone changes. Occasionally, a skin lightening agent can be used to help treat hyperpigmentation caused by acne also.
It is important to also address on the general quality of the skin as well as treating the acne scars per se. This helps to reduce the overall appearance of
Laser Treatment for Acne Scarring
FRACTIONAL CARBON DIOXIDE LASERS have been an even more recent development that can provide superior results to Fraxel treatments. Fractional carbon dioxide lasers are ablative lasers, that is, they vapourise columns of skin as well as heat the skin. By ablating as well as heating the tissues, more collagen stimulation and new skin formation occurs and it is possible to achieve superior results to non-ablative lasers like the Fraxel. The recovery period from fractional carbon dioxide laser treatment ranges from 3 to 10 days depending on the intensity of the treatment. The results from fractional carbon dioxide lasers are particularly effective in the treatment of acne scarring in fair skin types. For olive or darker skin types, there may be an increased risk of post-inflammatory hyperpigmentation (darkening of the skin post treatment), and for these skin types, we recommend Infini radiofrequency needling treatments.
Our Q-SWITCHED ND:YAG LASER, which is used also for tattoo removal and pigmentation removal, can also be used at settings to help promote collagen production and help improve mild superficial acne scarring to help raise small indentations in the skin. The advantage of this treatment is that it has only a small amount of downtime in comparison to the above treatments, however multiple treatments need to be performed. Usually, several treatments are required. There have been clinical studies showing the effect of this laser on flattening the topography of scarred skin, and a general overall improvement in skin texture and smoothness. Generally, this treatment is very mild, and not particularly effective in the treatment of acne scarring.
Micro-needling is another form of skin needling that utilises fine needles attached to a stamping device that oscillates up and down to create thousands of micro-injuries to the skin. It generally is a lot less invasive than and although it has less downtime, generally requires more treatments to achieve similar results.
Non-Laser treatment for Acne Scarring
Surgical skin needling is an older but very effective method of treating superficial acne scars by puncturing the skin with multiple fine 3mm (long) needles attached to a small rolling pin. This stimulates collagen production and helps to lift any ‘indented’ or atrophic acne scars. The advantage of this treatment is the fact that it can be used on all skin types including olive and dark skin types. People of Asian, Indian, African, and European background can have this treatment with less risk pigmentation changes in comparison to laser treatments post-needling. Also, it penetrates very deeply so that collagen can be stimulated on deeper acne scars. Usually it takes 3 to 7 days to recover from the treatment, depending on the degree of the treatment.
Micro-needling is another form of skin needling that utilises fine needles attached to a stamping device that oscillates up and down to create thousands of micro-injuries to the skin. It generally is a lot less invasive than surgical skin needling (described above), and although it has less downtime, generally requires more treatments to achieve similar results.
TCA CROSS is a simple yet effective method of improving acne scarring. It is most commonly used for small indented acne scars. It involves careful placement of high concentrations of trichloroacetic acid into the scar with a toothpick. This stimulates the production of new collagen and remodelling of existing collagen to fill in the acne scar. The advantage of this treatment is that it is localised to the problem only and not the unaffected skin.
Submission is another technique that is suitable for treating depressed acne scars. The size of the scar usually needs to be fairly large or deep. It involves putting a special needle under the depressed scar. Often acne scars are depressed because the skin is tethered to the underlying tissues
Chemical peels are another method of treating more superficial acne scarring. Generally, medium to deep chemical peels are required to achieve a significant result, but a series of more superficial chemical peels could help achieve some improvement in milder acne scarring without significant downtime.
Number of Treatment and treatment result expectation
Although there have been many advances in the treatment of acne scarring, it remains a difficult skin concern to correct. In most cases, an improvement is achieved, but due to the nature of the problem (scarring), it is not possible to completely remove scarring in most cases.
Most of the treatments described require multiple treatments to achieve the best result. Each treatment stimulates remodeling of the skin’s collagen, and to get the best results. As a general rule, we allow 2 months as a minimum period between treatments. This time interval between treatments is a balance between the time required for new collagen to form and the patient’s desires to achieve results quickly. New collagen formation can occur for up to 1-year post treatment, but patients are usually reluctant to wait a full year prior to deciding to retreat.
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