Acne scarring treatments are one of the most sought after medical aesthetics treatments in Singapore and with good reason. Unlike many skin conditions which can be covered up, the uneven craters of acne scars resist camouflage despite thick layers of makeup.

Acne scars form due to abnormal skin healing after acne-induced inflammatory damage to the dermis. Patients with atrophic or sunken scarring tend towards prolonged inflammation that causes collagen destruction. Raised hypertrophic or keloid scars result from over-exuberant healing that deposits excessive collagen.

The large majority of acne scarring that I see in Singapore is of the atrophic type so I will mainly address atrophic acne scarring in this article. Patients with atrophic acne scarring have often tried numerous touted remedies ranging from:

• beauty salon facials (totally useless!)
• home-based scar creams, home use devices like microneedling (cheap but minimal effects)
• numerous sessions of fractional lasers, erbium, eCO2, Fraxel.. the list goes on (burnt skin and massive downtime)
• thousands of dollars of Infini / Secret RF at celebrity-endorsed aesthetics clinics (expensive and painful but somehow results below expectations)

Yet, a common thread from what many patients tell me during new consultations is that nothing they have tried seems to work! Of course, it is not realistic to expect a 100% cure for acne scarring resulting in baby smooth skin. After all, permanent damage is already done. But, surely there should be at least some visible improvement to the skin texture and the depth of scarring?

Yes, acne scarring can be one of the most stubborn conditions to treat, and it is a long and difficult process to repair what is broken. Nowadays though, I have personally seen obvious improvements with new technology and treatment protocols. Many of my patients actually feedback that they can see more visible results in much fewer sessions that they would never have experienced with older lasers. Yet some doctors are still using older technology and don't see much results with the newer treatments.

Why the disparity?

After analysing the difference between my techniques and the standard protocols practised by many aesthetics clinics in Singapore, I have identified 3 key differences that could drastically improve the outcome of your acne scar treatment:

Not Getting the Basics Right

What are the basics of acne scar treatment? Aggressive acne control and making sure that we are indeed treating acne scarring.

First, aggressive acne control is key. No matter how drastic the improvements to your existing scars, you’ll never notice the difference if new scars form constantly from poorly controlled acne. If atrophic scarring has already developed, you are likely to form new scars and we should not waste any time messing around slowly trying topical treatments, etc. Rapid and effective treatment should be started with both lasers and oral medications concurrently with scarring treatments.

Secondly, when patients refer to acne scarring, quite frequently they are referring to another skin lesion that appears after acne spots heal - post-inflammatory hyperpigmentation (PIH). PIH should not be treated with the same techniques as atrophic acne scarring as it is not true scarring. Most aesthetics clinics in Singapore would treat PIH with picosecond q-switched lasers but I find that while these can help, results can be slow requiring numerous sessions. In most cases, a fractional ruby laser can obviously lighten PIH within a fraction of the sessions required by pico lasers.

Trying to Treat All Types of Acne Scarring with Machines

Atrophic acne scarring can come in many shapes and sizes, and it takes some thinking and planning to determine the best way to tackle individual pattern of acne scarring. If you’ve ever gone to a beauty salon or aesthetic clinic that tries to sell you a huge package of treatments promising that this one treatment will magically fix all the scars you have, maybe you should seriously reconsider.

Not all types of scars are best to treat with energy-based devices such as fractional lasers or microneedle radiofrequency. Of course, when you only have a hammer, every problem looks like a nail. Often, utilizing auxiliary techniques or combining these with machines yields better or faster results.

1. Surgical techniques

For suitable scars (especially small deep ones), surgical techniques for scar reconstruction (such as excision or focal ablation) can be very effective. For example, I had a patient who had a deep cheek scar for which he had subcision and fillers elsewhere but came to me as the scar had reappeared.

Most doctors would have tried in vain to use lasers and other energy devices to stimulate enough collagen to level out the scar, which would have taken many many sessions with modest results. Or they might have tried subcision again where the scar might look better but eventually sink down again once the filler is absorbed.

Having done many plastic surgery postings during my government service, I am familiar with facial wound closure. I excised the entire scar, eliminating the sunken area once and for all. Of course, this replaces the sunken scar with a new linear scar but this new linear scar is thin and can be cunningly positioned along the natural creases of the face. A few more sessions of fractional laser to smooth and blend in the area and most people would be hard-pressed to spot any scar.

Of course, knowledge of plastic surgical wound closure techniques as well fine and delicate stitching technique is required so that the resulting scar is as inconspicuous as possible. Not all aesthetics physicians can pull this off, and good judgement is required on when to utilize excision.

2. Subcision and filler

Not all rolling scars would benefit but this should definitely be considered for tethered scars in which the scarring is actually between the skin and the underlying muscle (Superficial Musculoaponeurotic System or SMAS) layer. Subcision and filler may be more appropriate to release scar bands at this very deep level.

3. CROSS (chemical reconstruction of skin scars)

The CROSS technique can work well for small ice pick scars, however, it carries a risk of broadening the scar in some patients with poor healing. Hence it has to be used very carefully with great control. I favour using a fine needle over the traditional toothpick for more precise positioning.

Not Using Energy Devices Appropriately, or with Poor Technique

Back in the old days when fractional lasers were the gold standard, all sorts of methods were cooked up to improve the effects on scarring:

• use very short pulses (ultrapulses) for more penetration
• modulate the pulse profile for more thermal coagulation
• stack multiple laser pulses for more penetration
• add radiofrequency energy to promote more collagen production

The effect of all this tweaking was… Underwhelming to say the least. Many sessions were required before seeing a small improvement. Patients often gave up before seeing changes because they lost hope.

Worse still, some clinics would sell cheap packages of many sessions of ‘fractional laser’ (similar sales tactics to the q-switched laser toning craze a few years back) but the doctors would use very low settings and quickly go over the whole face. If you understand how fractional lasers work, you’ll realize that such treatments do not penetrate deep enough to the level of the scar tissue. You could do a thousand of these ‘fractional lasers’ with zero results to show for it. Sadly, this is often what comes of shopping around for the lowest bargain-basement prices.

Having said that, even if your doctor had the latest greatest fractional laser, I find that the results of fractional lasers generally disappoint for scarring. This is because of how the laser energy interacts with the skin. The layer of skin where scarring occurs is deep in the second (dermis) layer. The laser has to be powerful enough to penetrate deep enough to break up the scarring and stimulate collagen remodelling. Yet this light energy has to first vaporize the first (epidermis) layer of the skin. Because the epidermis protects the skin from the environment and contains the pigment-producing melanocytes, excessive damage to the epidermis leads to prolonged healing times as well as the risk of pigmentary changes like PIH.

In short, it is very difficult to use a fractional laser to adequately break up scar tissue without getting into massive downtime, pain and PIH. Of course, there are ways to compensate, for example, using high settings and low treatment density or the other tweaks mentioned in the first paragraph of this section. But it wouldn’t make much sense to insist on using fractional lasers when we have other better tools.

Fractional microneedling radiofrequency is definitely more effective than fractional laser, which in my experience should be restricted to superficial textural blending. Unlike fractional laser, fractional microneedling radiofrequency uses microneedles which penetrate the skin to a preset depth and deliver radiofrequency energy deeply and precisely. This minimizes epidermal damage, removing the greatest limitation of the fractional laser. However, some doctors claim that fractional microneedling radiofrequency doesn’t actually produce better results. Yet others cite published articles comparing the two, showing minimal differences in results.

Why have these doctors not been able to achieve visible changes despite using a technically superior instrument?

I think, like many things, the crux lies in how the instrument is used, rather than the technical differences between each particular brand for example Infini vs Explore vs Intracel vs Secret RF.

I’ve realized three major nuances many doctors don’t:

1. Appropriate Treatment Intensity

In fractional microneedling radiofrequency, the treated tissue volume is much smaller per pass compared to fractional lasers. Most fractional microneedling radiofrequency devices have insulated microneedles which limit the treatment zone to about 300 microns at the tip of the microneedles. In a typical pass, only approximately 0.5% to 1% of the surface area is treated, and at a very specific depth - compare to this to fractional lasers where we can set a 10% surface area coverage that treats the skin all the way from the surface to a specific depth (depending on the power setting).

Now, this limited treatment volume is actually a good thing because it allows doctors to precision target energy delivery. However, this also means that to adequately break up scar tissue and stimulate collagen remodelling, many passes have to be done and at different skin depths.

This is something that not many doctors realize or practise! Just doing a couple of passes at low settings may be faster, easier and less painful, but the results are predictably much less as well. Of course, aggressive treatment protocols require much more experience, care, time and effort to perform while avoiding complications. So that’s something you should be aware of when deciding, instead of blindly choosing the cheapest clinic.

2. Effective Pain Control

Now that we’ve talked about appropriate treatment intensity to produce results with fractional microneedling radiofrequency, there’s another facet that is poorly addressed by most aesthetics physicians in Singapore: Pain.

Fractional microneedling radiofrequency is quite painful even at low settings. It’s rare to have patients tolerate the multiple passes at various depths required to treat to the correct treatment endpoint. This is another reason (other than the additional time and effort required) that doctors often stop after performing a cursory few passes at low settings and depths. Because the patient can’t tolerate it!

Patients are a lot more comfortable with local anaesthesia, but to properly and completely numb the face is not so simple. Multiple injections need to be performed to block the facial sensory nerves, and even then that only numbs the central face. More often than not, scarring extends to the sides of the face and temples, which are not covered by facial nerve blocks. Hence, complicated techniques may be employed involving tiny but long spinal needles, blunt injection cannulas or multi-needle mechanized injectors. The whole process can take 20-30 minutes - sometimes this takes longer than the actual treatment.

I would consider local anaesthesia almost essential for most patients that wish to have a proper fractional microneedle radiofrequency scar treatment - the difference in comfort can be night and day. Sadly, many doctors often do not have the time, experience or tools required.

3. Treatment Technique

Fractional microneedle radiofrequency may offer a lot more control over the depth of skin injury but it is actually a lot more operator dependent than fractional lasers. With fractional lasers, there is almost no concern that the treatment will go too deep or too superficial but with fractional microneedle radiofrequency, sloppy technique or the wrong settings can lead to disaster.

Proper depth settings are crucial. Skin thickness and scar depth varies across different areas of the face and among individual patients. It takes a practised eye and detailed examination to choose the right settings. Too superficial penetration can lead to suboptimal results and track marks since energy is delivered too close to the surface. Conversely, some doctors have the mistaken notion that deeper is better and thus set over-aggressive depth settings - this runs the risk of facial fat loss which looks terrible!

At the same time, even if the right settings are used, a practised hand is still required to ensure that the needles penetrate properly and evenly. Scarred skin is often much more difficult for the microneedles to push through, especially along the curves of the face. A loose grip with uneven pressure can result in the needles not penetrating deep enough. Proper technique utilising firm and even pressure, together with counter traction with the other hand, helps ensure correct energy delivery - reducing the chances of track marks and improving results.

Can Acne Scarring Treatments Work?

With the proper application of new technologies in combination with surgical techniques, visible results can realistically be achieved for acne scarring. Correct technique, in-depth understanding of each treatment and an experienced doctor makes a big difference in how much a particular treatment will help.

Are you still harbouring doubts about how to best treat your acne scars in Singapore? Feel free to drop me a message, I'll be more than happy to advise!

References

1. González N, Goldberg DJ. Update on the Treatment of Scars. J Drugs Dermatol. 2019 Jun 1;18(6):550.
2. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 2: Energy-based techniques. Scars Burn Heal. 2018 Aug 16;4:2059513118793420.
3. Taub AF. The Treatment of Acne Scars, a 30-Year Journey. Am J Clin Dermatol. 2019 Oct;20(5):683-690. doi: 10.1007/s40257-019-00451-9.
4. T. Gerald O’Daniel. Multimodal Management of Atrophic Acne Scarring in the Aging Face. Aesthetic Plast Surg. 2011 Dec; 35(6): 1143–1150.
5. Weiner SF. Radiofrequency Microneedling: Overview of Technology, Advantages, Differences in Devices, Studies, and Indications. Facial Plast Surg Clin North Am. 2019 Aug;27(3):291-303.
6. Chae WS, Seong JY, Jung HN, Kong SH, Kim MH, Suh HS, Choi YS. Comparative study on efficacy and safety of 1550 nm Er:Glass fractional laser and fractional radiofrequency microneedle device for facial atrophic acne scar. J Cosmet Dermatol. 2015 Jun;14(2):100-6.