Acne scars – what are my options to make them better?
What can be more frustrating than, after battling acne for years, having to start a new battle? Acne scars have been a cause for psychological stress, anxiety and depression. They are challenging to treat, but some new approaches have been investigated and have shown promising results. These are skin resurfacing with non-ablative fractional lasers (NAFL) and microneedling with radiofrequency (MNRF).
I thought today we could have a look at what treatment options are available in addressing acne scars (typical sequella of acne vulgaris) at the moment. I did a little research on the topic, and I would like to share this with you today.
What is acne vulgaris? It is the most common inflammatory skin condition, affecting 95% to 100% of adolescent boys and 83% to 85% of adolescent girls. In many cases it continues into adult life.
95% of people suffering from acne vulgaris have as a permanent consequence – acne scarring.
About 30% of people end up with severe form of scarring.
The consequences of acne scarring on our self-esteem can be profound. Many adolescence and adults report increased anxiety and depression and low self-confidence. Our social lives and relationships, academic performance and careers suffer as a result. We desperately need some effective options to address this problem.
How are scars formed? The chronic skin inflammation caused by acne vulgaris alteres the balance between skin matrix degradation and collagen production. Excessive collagen production results in hypertrophic scars, which are raised and thick. Between 80% and 90% of acne scars are atrophic. They result from insufficient collagen formation. Atrophic scars come into different shapes like “ice pick” (V-shape), “boxcar” (U-shape) and “rolling” (M-shape). All of them represent a treatment challenge. Most patients have a combination of these scars, which require different treatment approaches.
“Ice pick” scars are the most common type (60%-70%). They are usually narrow and deep and are least responsive to treatment. “Boxcar” scars are the second most common type (20%-30%). They are mostly wide and shallow. Their response to treatment is better. The “rolling” type (15%-20%) of scars is moderately responsive to treatment. They have a jagged appearance, with tethering of the overlying skin to the underlying fascia.
Many treatment options (both non-surgical and surgical) have been developed to address the acne scarring. Among others are dermal fillers, dermabrasion, microneedling, chemical peels, trichloroacetic acid and platelet-rich plasma injections. Plastic surgeons have developed some surgical options like subcision, punch excision, punch grafting, punch elevation, and elliptical excision. Other treatment approaches have proposed energy-based devices for skin resurfacing such as ablative fractional laser (AFL), non-ablative fractional laser (NAFL), and microneedling with radiofrequency (MNRF).
NAFL and MNRF are viewed as first line treatment in acne scarring
The current gold standard for skin resurfacing are ablative non-fractional lasers and ablative fractional lasers. These work by delivering a wavelength of light that vaporises the epidermis and dermis. Lasers use photothermal energy and are dependant on skin type and pigmentation. The clinician can select a specific dermal penetration depth. AFL produce microthermal treatment zones with this wavelength of light. These are surrounded by untreated and healthy epidermis and dermis, which reduces the downtime of treatment and promotes re-epithelialisation. However, ablative lasers have limited use due to their longer recovery times and increased risk for post-treatment complications. Despite the advances in lasers there are still two disadvantages that remain. The heat affects the epidermis and dermis with the highest heat at the surface of the skin, darker skin tones can develop hyperpigmentation. The other problem is impared and prolonged healing of the skin of the neck when exposed to deep dermal laser procedures. This is due to the lack of pilosebaceous units in the skin of the neck. Patients demonstrate much better tolerance to the less aggressive NAFL and MNRF. They reoprt quicker post-operative recovery and much less post-operative complications. Their popularity in clinical practice has grown immensely.
NAFL can be used as single treatment. It works by generating thermal energy in microscopic columns delivered to the epidermis and/or dermis keeping the integrity of stratum corneum. This energy stimulates the fibroblasts to produce collagen and elastin. The clinicians have a very precise control over the energy delivered to the dermal layer.
MNRF is a procedure in which microneedles pass through the epidermis with minimal damage. The microneedles generate electromagnetic radiation which causes mild thermal injuries in the dermis. As a consequence fibroblasts are stimulated, growth factors are released which leads to production of collagen and elastin. Skin’s resistence (impedance) is dependent on its hydration, elecrolyte composition, collagen content, temperature etc. Clinicians are able to deliver the electromagnetic radiation to different layers of the dermis by adjusting the level of penetration of the needles through the skin. The adjustments depend on the severity and type of scarring. Through out the face, the skin depths vary from 0.37 mm (eyelids) to over 2 mm. In some cases facial acne scars require deeper treatment depths like 2.5 mm to 3.5 mm.
NAFL and MNRF are most appropraite treatment options for people with moderate to severe acne scarring. Before commencing any treatment it is essential to have a thorough discussion with patient about treatment protocols, risks and benefits, alternative treatments and expected results. Guiding patients towards realistic expectations for improvement is essential. They need to be aware that deeper atrophic acne scars usually require multiple treatment sessions. Before starting the treatment, we need to have baseline photographs of the treatment area. New photos should be taken at each visit to monitor improvement.
In most cases, NAFL and MNRF are provided at the same visit, however if patients are at risk of prolonged healing or are prone to hyperpigmentation, these treatments can be spaced out and/or alternated at 2 to 4-week intervals. This, however will result in prolonged total treatment time and slower and reduced improvement.
Before starting the treatment with NAFL, the clinician should apply an even layer of topical anaesthetic (30% compounded lidocaine ointment; EMLA) for 45 to 60 minutes to the treatment area. This will improve patient’s experience. In the next step the topical anaesthetic should be removed with a gauze and the skin should be sanitised and degreased with alcohol or chlorhexidine wipes. The patient should be positioned comfortably on the treatment bed, and each device should be close enough for the handpiece to easily reach all the areas to be treated. Standard laser safety protocols should be followed, including eye protection for patient and clinician. The clinician should confirm that patient does not have a pacemaker in place in MNRF procedures.
For NAFL it is recommended to treat the whole face in order to avoid a treatment demarcation line. For NMRF the treatment can be focused only to the area of scarring. For NAFL the treatment sequence starts with cheeks, followed by chin and upper lip, nose and ends with forehead. The handpiece should be positioned along the skin surface and moved in a single back-and-forth motion, with 50% overlap between each row. This motion should be repeated perpendicularly in the same treatment area to allow a total of 8 passes. As a result we can expect mild redness and swelling.
For MNRF at the start of treatment pure glycerine is applied to the skin and the target area is pre-heated (67 C). Because of this pre-heating of the treatment area some authors don’t recommend to use topical numbing because of the risk for burning of the skin. If insulated needles are used the epidermis is protected from heating and the energy is delivered in a more precise way to the dermis. The handpiece should be directed perpendicular to the skin surface with mild pressure to avoid overpenetration of the needles. It should be held in full contact with the skin for the duration of the pulse (3 to 5 seconds). The pulses should not overlap in order to avoid overtreating of the area. At the end of the procedure, there are minor pinpoints with bleeding. It is important throughout the treatment to ensure patient’s comfort. Pulse duration is usually corelated with level of patients’ discomfort. The efficacy of “painless” MNRF should be questioned as the delivery of energy in the mid-dermis is inheretantly painful. For this reason the application of topical anaesthetic or local anaesthetic is usually recommended. Procedure times vary between 15 and 60 minutes and depend on the device used.
When MNRF treatment is finished, the skin should be cleaned with a wet gauze with mild pressure to stop any minor bleeding. This would be a good time to apply topical vitamin C serum. The micro-channels created in the skin enhance topical absorption. They can remain patent for varying duration post treatment (usually between 6 to 12 hours), depending on the size of the needles, depth of dermal penetration and the energy delivered. A good recommendation for the post-operative period is a direct application of ice packs to the treated area which will help with the mild bruising and swelling. For 3 to 5 days following treatment, patients are advised to avoid harsh and abrasive topicals like scrubs, chemical exfoliants and retinoids. They can use a gentle skin cleanser and emollient moisturiser. Patients are strongly advised to use sunscreen with SPF 30 or 50. Before the procedure patients should be informed that their skin may have mild redness, it may feel tight and rough for about 5 days after the procedure. If they want, they can resume makeup in 2 days post treatment.
Combination NAFL and MNRF therapy has a superior effect in patients with moderate to severe acne scarring compared to monotherapies.
Patients have shown remarkable tolerance to the combination treatment. It has shown to be safe for all skin types. Some common side effects include transient erythema (redness), oedema (swelling), burning or itching sensation. There are possible risks for postinflammatory hyperpigmentation, acneiform eruptions, prolonged erythema, and scarring from NAFL and a risk for folliculitis, crusting, and grid marks from MNRF. Patients did not report much differences in post-operative pain. One very important advantage of combination therapy were the very rarely experienced complications like secondary infections or hypertrophic scarring.
There are treatment options available if patient developed any of the side effects from these energy-based treatments. Topical hydroquinone, tranexamic acid, kojic acid or vitamin C, as well as topical tretinoin or oral tranexamic acid can be used in case of post-inflammatory hyperpigmentation. In some cases patients start treatment with lightening agents a few weeks or months prior to combination therapy with the intention to prevent hyperpigmentation post-treatment. It is recommended for NAFL treatments in patients with darker skin tones to reduce the density and flow of the generated thermal energy. Prolonged erythema is usually self-limiting within several months. It can be treated with monoxidil. Acneiform eruptions and folliculitis respond well to topical clindamycin, topical benzoyl peroxide and oral doxycycline.
The treatment of acne scarring, remains a challenge. The scars can vary widely in type and severity, for this reason individualized treatment plans are paramount for achieving optimal results and different approaches are often recommended.
Thank you for reading this piece. Thanks to all the researchers who developed these new strategies for acne scar treatments. I am very grateful to learn from you. It was very interesting for me to read about this topic and to share with you, hopefully answering some questions. The information is based on 2 scientific articles, listed as references.
Please, share your thoughts in our comments.
Till next time.
Venelina
References:
Coerdt, K., Rajanala, S., Steuer, A., & Dover, J. S. (2025). Combining Non-ablative Resurfacing with Radiofrequency Microneedling for Acne Scarring. Advances in Cosmetic Surgery. https://doi.org/10.1016/j.yacs.2024.12.002
Weiner, S. F. (2019). Radiofrequency microneedling. Facial Plastic Surgery Clinics of North America, 27(3), 291–303. https://doi.org/10.1016/j.fsc.2019.03.002
