What is the best way to remove acne scars on my face? Fraxel, Chemical Peels, or something else?

Facial acne scars are undoubtedly one of the most emotional and psychological traumatic experiences that a young person can live through.  Acne scars occur when someone has a history of acne which causes tissue injury and the body attempts to repair itself.  Instead of the natural smooth skin, one is left with scars of different types: some are called ice pick scars, some raised, some atrophied, and some depressed.  Whatever the scar, they cause a general feeling of insecurity, inferiority, and embarrassment which leads to low self-esteem. People can be pre-occupied with these thoughts, withdraw from society, become angry, frustrated, or even depressed. It affects personal relationships and careers.   In the past, acne scars have been treated with dermabrasions/microdermabrasions and chemical peels – both of which were limited in that they only affected the superficial layers of skin which could help possibly with post-inflammatory hyperpigmentation but the deep scars were unscathed.  Collagen was also used.  They were injected into the skin to “stretch” and fill out scars.  However, only certain types of scars could be treated and patients would have to be pre-tested for allergies to bovine which made it inconvenient and impractical. Surgery using punch excision was an option used to remove individual scars, but they couldn’t address the entire face and the surgery itself could make scars worse. Finally, ablative lasers using CO2 were developed in the 1960’s.  It used a continuous beam of light energy to vaporize the uneveniness of the scar while causing collagen remodeling of the deep layers. They had the most impressive results but the procedure itself was extremely painful necessitating general anesthesia.  In addition, there were weeping wounds which had to be cared for many weeks.  Also, there were potential for infections.   Since lasers seem to be the most promising method, in the past decade, there has been great advances in laser technology to deliver less painful and safer treatments with results approximating the traditional CO2 laser.  It involves the process of “fractionation.”  Instead of treating the whole skin, only certain fractions in randomized but calculated areas are treated.  The untreated areas allow for skin to heal faster which leads to less downtime and pain.  Nowadays, there are at least half a dozens systems out in the market that fractionate CO2.  Fraxel came out with their system this year called the Fraxel Repair.  Lumenis makes another called the Active/Total Fx.  There's the Mixto.  There's one from Sciton.  The point is there is plenty out there.  They vary on how deep they penetrate the skin.  There is no consensus on how deep one needs to go down to have the most optimal results.    In general, the deeper the penetration, the more uncomfortable the treatment. These treatments usually require 4-7 days of downtime where the face is red and swollen followed by 2-3 days of peeling of the skin.  During the procedure, the face is anesthesized topically and patients often take oral medications.  The procedure is still uncomfortable and somewhat painful but for most, it is tolerable.  However, no general anesthesia is needed anymore.  There is some minimal post procedure care that is required but it is fairly simple and straightforward (no more issues of weeping wounds.)  Risks of the treatment include burns, scars, infection, hyperpigmentation, or hypopigmentation.   In conclusion, for best results, I would recommend an ablative fractional CO2 laser.

When it comes to acne scars, this is what I usually tell my clients 1.  Make sure that your acne is controlled.  There is not point in spending money on expensive treatments to reduce the scarring, if you are just going to develop new scars.  Easier said than done, I know, but ultimately possible. 2. Realize that no treatment will make your skin baby smooth again.  You must go into acne scar treatments with realistic expectations.  You scars will improve, but unless they are very superficial, they won't go away 3. I believe that of all the treatments currently available, the fractionated lasers offer the best acne scar reduction.  You will want to choose a treatment with deep dermal penetration for optimal collagen stimulation such as Lumenis Deep FX or Fraxel Repair.  The older non-fractionated CO2 lasers are also excellent at reducing acne scarring but the down-time is extreme and the liklihood of permanent pigment change is high 4.  Fillers such as Juvederm or Perlane can be helpful for deep scars, but the results will not last nearly as long as with the laser.  I do have patients that choose to have both fillers and lasers.

Acne Scarring can be a very frustrating problem for many patients. The severity of scarring can range from mild irregularities to deep (ice pick) scars. The two major methods for treatment are those that either a) fill in the irregularities from below or b) smooth or resurface the skin down to one smooth level. Fillers such as Juvederm or Elevess can push up the deeper scar from below. They provide moderate relief, but evenutally wear off. Resurfacing treatments range from mild chemical peels, microdermabrasion and fractional CO2 laser resurfacing fro mild scarring to deeper CO2 laser or deep chemical peels for more severe scarring. All treatments seem to trade off results for convenience - mild treatments give mild results with little downtime, whereas deeper, more aggressive treatments give better results at the cost of more downtime.