Review of acne scar lesions, how they form and available treatment

How to treat acne scars is of great concern to patients with moderate to severe acne. Failed or inadequate treatment of acne is major cause in development of acne scars. The incidence of these sequels is not known. It is frequently stated that acne scars result from severe inflammatory nodulocystic acne lesions occurring deep in the dermis. Although it may exist with only minor more superficial acne lesions. It is very likely that some patients are further prone to scars based the factors that define their skins. Of paramount importance that acne should be treated early and adequately. Following factors may be stated as involved in etiology and introduced as causes of different types of acne scars.

• A scar can be natural consequence of inflammatory acne or result of self manipulation.
• An skin injury that extends into the dermis layer, it is always associated with development of a permanent lesion.
• Nodular forms of active acne such as cystic and nodular acne are more likely to form acne scars and an acne spots.
• Infection is another involved factor in acne that comes into play and results in severe acne caused skin lesions.
• Location of the comedone breakouts also becomes an important factor. Areas of the face with better circulation heal exceedingly faster. Temples, which have less circulation, respond poorly. Acne lesions may produce sequels that are thickened or, more commonly, depressed.

Scar formation and its pathology

The following wound healing scenario may explain the pathology of acne scar. The initial step is defined by a structured series involving inflammatory cells. This succession of episodes is arranged by neutrophils. Subsequently, macrophages elaborate a variety of cytokines, which create an environment prone to granulation tissue constitution. Eventually, migration of fibroblasts coincide with proliferation and recapitulation by depositing new collagen. Simultaneously, formation of new capillaries is triggered by some factors released in the wound section. A problem arises when this organized cascade is disrupted by its anabolic and catabolic phases. An overreacting wound healing response may happen, creating a bulgy lesion of fibrotic tissue. Alternatively, deleted connective tissue is deficiently replaced and forms a pitted appearance resembling the surface of a golf ball. In either case, the scar often is a legacy of skewed healing process. Pathology of acne spots, however, have less correlation with anabolic and catabolic stages, rather, skin pigmentation changes arise prominently.

Types and prognosis

There are basically two types of scars. One is associated with propagated tissue formation and the other is associated with some tissue loss

Types with increased skin tissue:

Keloids: They present as smooth, firm, irregularly shaped lesions. Upper body or angle of the jaw are more prone to these type of facial lesions. Skin of dark-complexions (black skin) is more predisposed to develop hypertrophic scars. They could be regarded as thick, raised, lobulated fibrotic plaques. Types with increased skin tissue rarely observed with acne lesions.

Types with loss of skin tissue:

Acne spots: Flat discolorations either brown or red.They are more likely to fade away either gradually without treatment or using fading creams. Post inflammatory pigmentations are classified in the same category. Blocks of pink hyperpigmentations seen following skin breakouts.

Ice-pick lesions: They may be superficial or deep, fairly linear but irregular and generally turn out on the cheeks. These lesions are variably resistant to the treatments and the more penetrating they are the longer it takes to be healed totally.

Depressed fibrotic scars: They present as large with sharp margins and steep sides. Their base is rigid, white and can not be stretched. They may result from severe lesions such as cystic and nodular forms of acne.

Atrophic scar macules: This type of lesions manifest as soft, distensible, ivory-white in color and small in size (few millimeter in diameter). Acne is recurrently associated with atrophic type.

Scars are result of improper deposition of collagen and elastin and insufficient wound healing process. Lining epithelium is not flat and atrophic but hyperplastic. Healing them involves inducement of the skin's healing process and rebuilding elastin and other fibers. Overall they have a good prognosis. They do not expand in size or number over time. However, aging has an adverse effect on them and render them more pronounced.

Prevention:

The more acne inflammation persists the more likely development of acne caused skin lesions are. Treatment promptly in its course is the best method for prevention of acne damages. Use of anti oxidants as a preventive method especially vitamin E is still viewed with skepticism, some studies even report a harmful effect. Powerful anti oxidants such as alpha lipoic acid when employed alone works with no success. A favorable medication for acne essentially address the following problems: An elevated sebum synthesis, overproduction of epithelial cells lining follicles, bacterial involvement, more inflammation in acne sites. Read also next page for more prevention tips.

Treatment of acne scars, different removal techniques for facial restoration

Most have heard of chemical peels, dermabrasion, silicone injections, collagen implants and laser skin resurfacing since these have been widely publicized in the lay press. For the patient whose acne has recently cleared, it is worthy to know that scars tends to become less apparent with time and that any consideration of cosmetic surgery must be deferred for some time. Post inflammatory pigmentations tend to disappear in a few months. So post inflammatory pigmentations in most cases resolves spontaneously. It ought to be pointed out that lesions on the body does not tend to improve readily and is conventionally less amenable to cosmetic surgery.

Topical treatments, Oral treatments: Retinoic acid, alpha and beta hydroxy peels, potent anti oxidants such as alpha lipoic acid are widely discussed and debated in treatment of acne caused skin irregularities, spots and hyperpigmentations, scars and lack of skin uniformity. Among medications for damaged skin is retinoic acid. Despite showing some degree of improvement, its use alone does not bring about a dramatic conversion. Skin dryness and redness are among complications. Oral medications such as accutane are not very pleasing to most affected individuals and does not alter lesions to a noticeable extent.

Scar excision (subcision): This surgical method of treatment uses a scalpel or punch to remove the damaged skin. Under local anesthesia, the lesion is excised and the skin edges are then sutured together. Excision is typically recommended to patients with deep pitted marks that are not amendable to the TCA technique. Good for deeper marks. Longer recovery time

Microdermabrasion:

Dermabrasion involves controlled surgical scraping that resurfaces the outermost layers of the skin to give a smoother appearance. It can be done over the full surface of the face or on small areas. Dermabrasion also may be done in conjunction with other cosmetic procedures such as a chemical peeling or face lift. Dermabrasion is used to treat a range of skin imperfections including: Wrinkles and frown lines, pre-cancerous skin growths (keratoses), facial scarring (excluding burn scars, acne scars), post-surgery marks, skin pigmentation, sun damage, tattoos, age spots, facial freckles, acne spot and other acne scars.

Acupuncture: Use of acupunture to treat acne scars is considered a new approach. Use of small, very thin needles in the skin causes a tiny injury at its site which is associated with an increase in skin microcirculation and stimulation of inflammatory mediators. Infiltration of cytokines is chemotactic for fibroblasts and formation of new collagen. Acupuncture seems to be rather effective in improving appearance of atrophic acne scars. Facial acupuncture is becoming more popular not only for scar treatment but for other rejuvenating purposes.

Resurfacing of skin by laser. Another technique for acne scar removal appear to be more with a desirable outcome in convex regions of the face. Lateral cheek and the temples do not benefit from this office procedure as much. Laser resurfacing treatments could be associated with hyperpigmentation (increased skin color) or hypopigmentation (decreased skin color) for short or long term in treatment vicinities. Scars, infection and persistent redness are also possible side effects. With available medications these could be controlled. Some clinical testing suggest that high-energy, pulsed CO2 laser can safely and effectively improve or even eliminate atrophic acne damages and provides many contributions in contrast with traditional treatment means. Erbium, the latest technique, has generated more satisfactory results which leads to elimination of a superficial acne scars and a reduction in other forms of scars. Some research indicate that old severe acne scars responds substantially less to laser treatments while newly formed marks could almost completely vanish. This indicates that timing of treatment could be significant. Laser also have been utilized to treat acne particularly in patients who show sensitivity reactions to medications for acne. Outcomes are not very promising though.

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Scar tissue formation, an inflammatory response:

Skin healing and scar tissue formation is a complex process entails a number of overlapping phases, including inflammation, epithelialization, angiogenesis and collagen deposition. Ultimately these processes are resolved leading to a mature wound and macroscopic scar formation. Although inflammation and repair mostly occur concurrently, the sensitivity of the process is underscored by the consequences of disruption of the balance of regulatory cytokines. Consequently, cytokines, which are central to this constellation of events, have become targets for therapeutic intervention to modulate the wound healing process. Depending on the cytokine and its role, it may be appropriate to either enhance (recombinant cytokine, gene transfer) or inhibit (cytokine or receptor antibodies, soluble receptors, signal transduction inhibitors, antisense) the cytokine to achieve the desired outcome.

Response to injury in the skin initiated by coagulation and an acute local inflammation. This follows by mesenchymal cell migration, proliferation and matrix synthesis. Failure to resolve the inflammation can lead to chronic nonhealing wounds, whereas uncontrolled matrix accumulation, often involving aberrant cytokine pathways, leads to excess scarring and fibrotic sequelae. Manipulation of cytokines provides therapeutic opportunities to control abnormal wound healing and scar formation.

Connective Tissue Repair: where repair cannot be accomplished with resolution, scar tissue forms. Fibroblasts migrate to the site of injury and proliferate following stimulation by TGF-beta and many other cytokines and growth factors. New endothelial cells proliferate upon induction by VEGF. This forms granulation tissue within 3-5 days of injury. Granulation tissue is pink in appearance and characterized by the formation of new vessels, production of ECM, fibrosis, and initial repair that lays down the structure on which the final scar will be formed. Angiogenesis proceeds by formation of new leaky vessels from existing vessels. Basic fibroblast growth factor and VEGF induce angiogenesis. Fibrosis develops with deposition of ECM by fibroblasts. Collagen synthesis and decreased degradation of collagen gives strength to the healing wound. IL-1, TNF, TGF-beta, b-FGF all work to increase the production of collagen locally.

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