Addressing Acne Scars: An Update
Early, effective acne treatment can prevent scarring.
Acne is estimated to affect upwards of 50 million Americans every year, and approximately 85 percent of teens and young adults.1 It has been well demonstrated that acne has a significant impact on quality of life and is associated with depression, embarrassment, and anxiety.2 In addition to the emotional scarring that occurs when patients are suffering from acne, this common condition may potentially cause permanent physical scars. Acne scars may be more common in patients with severe disease, but they can occur even in those with mild acne. It has been estimated that approximately six percent of acne lesions may heal with permanent scarring.3-6
Acne scars may be broadly divided into two groups. First, depressed acne scars may be either of the rolling, boxcar, or ice pick variety. Second, raised scars may be either hypertrophic or keloidal. Acne scarring is thought to be the result of abnormal dermal remodeling after injury to the skin, and improper activity of matrix metalloproteinase enzymes are thought to play a pivotal role.7 There may also be a genetic susceptibility.
Treatment of acne scars has largely focused on skin repair after damage has occurred. In the early 20th century, dermabrasion and deep peels were common. Punch grafts became popular in the 1950s and are still used today. Injections of silicone and collagen began in the 1960s. Advancements in laser technology brought ablative laser resurfacing procedures as early as the 1980s, and have been refined to the fractional, nonablative lasers used today. Microneedling, subcision, newer injectable fillers, and trichloroacetic acid chemical reconstruction of skin scars (TCA CROSS) chemical peels (applied to individual ice pick scars) are now also commonly employed methods for treating depressed scars.8
Focus On Primary Prevention
While we can improve the appearance of acne scars, the best treatment is primary prevention. We know that delays in treatment and improper management of acne may increase the risk of developing scars. Appropriate use of the medications in our tool belts is essential to clear acne before scarring occurs. Extra caution should be exercised in patients who already have acne scars when they first visit the office so that no more scars develop.
Recently, data has been released evaluating the use of a topical acne medication in order to understand whether it can decrease the risk of developing depressed acne scars. In a Phase 4, multi-center, randomized, investigator blinded, vehicle controlled split faced study known as the OSCAR study, adapalene 0.3% in a fixed dose combination with benzoyl peroxide 2.5% (A/BPO 0.3%/2.5%, Epiduo Forte Gel, Galderma) was used to treat patients with moderate-to-severe acne. Patients were treated on either the left or right side with active drug and vehicle to the contra-lateral side of the face. For 24 weeks, patients treated the face, after which time they were evaluated. Statistical reductions in acne lesions occurred as early as week one, and continued throughout 24 weeks.
Statistically significant differences were seen in active treatment compared to vehicle gel with respect to clear/almost clear acne improvement as well as scar global assessment. At week 24, 32.9 percent of the Epiduo Forte side of the face achieved a clear/almost clear scar global assessment score as compared to 16.4 percent in the vehicle side. Moreover, the mean number of scars decreased over time with Epiduo Forte, while the mean number of scars increased over time with the vehicle.9
Early Intervention Matters
Modern technology has given us the ability to improve the appearance of acne scars in the skin through physical modalities like lasers. However, they do not take the place of early, effective acne treatment that can prevent scarring from developing in the first place. The data from the OSCAR study show that our acne medications do more than just improve active acne, as they can decrease the risk of developing acne and may even improve the appearance of acne scars themselves.
Joshua Zeichner, MD, FAAD is an Assistant Professor and Director of Cosmetic and Clinical Research in the Department of Dermatology at Mount Sinai Medical Center in New York
1. American Academy of Dermatology. Acne. https://www.aad.org/media/stats/conditions. Accessed March 19, 2018.
2. Gieler U, Gieler T, Kupfer JP. Acne and quality of life - impact and management. J Eur Acad Dermatol Venereol. 2015 Jun; 29 Suppl 4: 12-14.
3. Magin P, et al. Psychological sequelae of acne vulgaris: results of a qualitative study. Canadian Family Physician. 52.8 (2006): 978-979.
4. Layton AM, et al. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol. 1994;19:303.
5. Tan J, et al. Prospective study of pathogenesis of atrophic acne scars and role of macular erythema. J Drugs in Dermatol. 2017:566-572.
6. Tan J, et al. Development and validation of a scale for acne scar severity (SCAR-S) of the face and trunk. J Cutan Med Surg. 2010;14:156-160.
7. Kang S, Cho S, Chung JH, et al. Inflammation and extracellular matrix degradation mediated by activated transcription factors nuclear factor-kappaB and activator protein-1 in inflammatory acne lesions in vivo. Am J Pathol. 2005 Jun;166(6):1691-9.
8. Bhargava S, Cunha PR, Lee J, and Kroumpouzo G. Acne Scarring Management: Systematic Review and Evaluation of the Evidence. Am J Clin Dermatol. 2018 May 9. (Epub ahead of print)
9. Dreno B, Bissonnette R, Gegne-Henley A, et al. Prevention and Reduction of Atrophic Acne Scars with Adapalene 0.3%/Benzoyl Peroxide 2.5% Gel in Subjects with Moderate or Severe Facial Acne: Results of a 6-Month Randomized, Vehicle-Controlled Trial Using Intra-Individual Comparison. Am J Clin Dermatol. 2018 Apr;19(2):275-286.