Acne Scar Repair Series

One word- inflammation. If your skin is inflamed during your treatment process, your outcomes will not be optimal. It is not ‘relative control’ (relative to how severe your acne was), it is about absolute control. You can not build muscle if you have inflammation (secondary to muscle strains), the same thing applies to skin. Collagen formation is best in the absence of inflammation. 

A medical dermatologist can assist you in treating your acne if you are still undergoing breakouts.

The acne scar revision algorithm is complex as there are ‘optimal’ modalities for different scar signatures, coupled with variables such as skin type, downtime & patient expectations/concerns & wishes, the combinations can be confusing. For complex algorithms our specialist dermatologists are involved in scar treatment. They employ-

• Fully ablative lasers
• Deep RF devices
• Surgical excision
• Subcision
• Deep focal peels
• treatments

Dermatologists approach scarring at a specialist level, meaning we employ specific strategies to remove scar tissue & remodel collagen. As a guide, they are more ‘scar centric’, meaning they employ optimal treatments to treat specific scar signatures. Treatments include fully ablative lasers, excisional modalities (surgery), multi-level sharp dissection & subcision as well as soft tissue augmentation using treatments & fat transfer. Whilst in some cases these treatments are more effective, the recovery time is generally longer & so are the costs. 

*Cost associated with scar revision by a dermatologist comes down to the complexity required for revision, assistant times (nursing time), in addition to operating theater time.

Now for the fine print regarding scar revision & lasers. These are super important concepts to understand-

1. Cost vs outcome ratio. This treatment series is designed to improve acne scars whilst at the same time ensuring that costs are kept to a minimum. The way we keep costing down is to minimize the hands-on time by our dermatologists, hence why treatments are performed by our experienced nurses at Cutis Dermatology. 
2. Downtime vs outcome ratio. Though we rock the most technologically advanced laser systems, you must expect some element of recovery. Within reason, the longer the downtime the better the results. Recovery ranges from 48 hours to 6 days. Short recovery lasers include the Picosure & Alma Hybrid systems. 
3. Remainder biased. This refers to the scars that may not respond to this program. Remember that this series is designed to globally improve acne scarring. It is not designed to remove individual scars (however our nurses will do their very best to address your specific concerns). For individual scars, a specialist dermatologist may be involved. 
4. Treating darker skin types. Darker skin types are more complex, mainly because big settings with lasers will give post inflammatory hyperpigmentation, or skin darkening. Hence it is important to balance the outcomes, with the duration of PIH. Your clinician will discuss this with you prior to treatments. For gentle laser settings, your program may be extended to a second or third series of lasers.
5. Control of acne. Time & time again, this is one of the most important factors to consider because, firstly, this is under your control, & secondly it determines the efficiency of your immune system’s ability to remodel collagen & acne scarring. 
6. Additional treatments. Other treatments may be required to address reminder biased scars, or to treat scar types based upon scar signature. These include surgical revision procedures as well as soft tissue treatments & deep focal TCA peels. Targeted scar revision is performed by our senior consultant dermatologists. 
7. Age related changes. This is an important concept to understand if you have maturity on your side. After 20, collagen decreases by 1-1.5% per annum. This collagen loss adds to the deficit of collagen within atrophic scars. The older you get, the more you play catch up. If you can not replenish collagen, soft tissue dermal injectables such as Profhilo, PLLA, CAH & PCL injections can give you a helping hand. 
8. Variable outcomes. The bell curve. It’s reality. Some lie to the right of the curve & can produce & remodel more collagen than others. Ethnicity also plays a role. Darker skin types can remodel collagen more effectively than lighter skin types; at the expense of increased incidence of hypertrophic scars & hyperpigmentation. You can not alter genetics, but eating healthy & controlling skin inflammation gives you the highest chances of efficient collagen remodeling.
9. Skin health. Eating & living healthy makes a world of difference. Smokers often require 2-3 times more treatments than non-smokers.

Sure. At Cutis Dermatology Brisbane we employ the most advanced RF microneedling systems, including Genius RFM & Morpheus8 (coming soon). Though RF systems have some advantages over lasers (slightly faster healing times, less skin color changes in general), we find that lasers outperform RF devices when it comes to general improvement of acne scars. 

RF microneedling is best for deeper rolling acne scars, whilst lasers are much better for superficial acne scars, including boxcar, polymorphic, & shallow atrophic scars.

Fractional lasers have a high safety margin, however side-effects, though rare, can be encountered. They include-

• Flare up of pigmentation: melasma flare ups, rare & can be mitigated in most cases.
• PIH or post inflammatory hyperpigmentation. Defined as unexpected prolonged pigmentation, as opposed to predictable pigmentation seen in darker skin types. Treated with pico lasers & pigment inhibitors. 
• Persistent redness. Rarely seen with fractional lasers, may flare up rosacea, but treated with vascular lasers & anti-inflammatories. 
• Infection. Rarely seen with fractional lasers.

Select the correct tool for the job. A carpenter can build a table with a saw & hammer, but it won’t be a good one. The same applies to lasers & acne scar revision, hence why at Cutis Dermatology Brisbane we have a wide range of lasers and energy devices. Your clinician will select a correct laser for your scar revision series, based on your scar type, your skin color & your allocated downtime. Here are our thought processes when it comes to laser selection.

• eCo2 fractional CO2. Great overall laser, this device is good for most skin types & is powerful enough to treat deep rolling scars. 
• Hybrid Alma. Best laser for low downtime, additionally it can treat darker skin types with little to no downtime & post inflammatory pigmentation. 
• ProFractional HALO-erbium laser. Outdated, HALO by Sciton is not powerful enough to treat most scar types as it has 15 times less penetration (erbium) than Profractoinal. Our dermatologists may employ deep fractional erbium for some cases. 
• Fraxel Dual. Great for skin rejuvenation, but underwhelming for acne scars. Hybrid 1570 is better. 
• Fraxel RePair: Again outdated, better CO2 systems.
• Ultrapulse. Awesome for some types of scars, primarily used by our specialists. 
• Mixto. Good laser, but others better. We hardly use it. 
• YouLaser MT. Generation 1 hybrid, Alma system is generally better & more powerful. 
• CORE. Great laser for superficial scars, we occasionally use it. 
• Picoway. Best laser for post inflammatory hyperpigmentation. 
• Picosure. Best laser for small enlarged pores, general skin rejuvenation in darker skin types.