Which laser skin treatment is best for acne scars?

The reason there are so many options for acne scar correction, is because there are different types of acne scars and there are relative strengths and weaknesses to all modalities to correct or improve acne scars. It is therefore very important to seek the advice of a board certified dermatologist with experience in all modalities in order to pick the one best for you.

• Mild scars? Perhaps just SilkPeel or a series of peels is necessary.

• Can't afford downtime? Cooltouch might be perfect.

• Deeper scars? Fraxel Re:Store has been a true breakthrough, but does have 1-3 days of swelling that you must be prepared to experience. 

• Active acne? Isolaz may be for you.

• Finally, severe scars may benefit from true resurfacing either with traditional dermabrasion, or a fractional CO2 laser device like Juvia or Fraxel Re:Pair. These procedures have at least one week of social downtime, but give the most dramatic result.

Please get the advice from someone familiar with the options and prepared to provide the one best for you.

There are two excellent laser alternatives for acne scars.

The Fraxel Laser provides consistently good results, although depending on the depth of the acne scars, you may need 5 to 6 treatments spaced one month apart. You will generally observe redness (like a bad sunburn for about 3 days to a week) after each treatment.

The Erbium Laser such as from Sciton utilizes a laser resurfacing technique which can generate excellent results after one treatment, although it can be repeated to achieve even better results. Healing time is longer although it produces more consistently appropriate response.

Consult with a board certified plastic surgeon to determine which procedure is appropriate for you and your lifestyle.

There are so many entities out there claiming efficacy for treating acne scarring that it can become very confusing. These range from non ablative light based therapies such as Nd:YAG and Pulsed Dye Laser to fully ablative CO2 resurfacing. As with most things the treatments that offer the best range of results, side effect profile and downtime tend to be the patient favorites.

In our experience non-ablative lasers will max out at about 30-40 percent improvement with a minimum of five treatments. The best results usually require more like 8-10 treatments. Most patients favor these procedures for treatment of enlarged pores or fine lines and not acne scars.

On the other end, CO2 laser is the gold standard for results. There are a few downsides to full CO2 resurfacing. These include downtime, which can last several weeks with the possibility of having several months of residual redness. Discomfort and swelling may also last several weeks. Long term side effects such has permanent hypopigmentation (lightening of the skin) and scaring have been significantly reduced but still occur. Due mostly to the significant downtime, full CO2 resurfacing tends to not be the treatment of choice.

For most patients the best options are the fractionated lasers. These include things like Active FX, Deep FX and Fraxel re:pair (ablative CO2). When treating with a fractionated laser, there are patches of skin that are not affected by the laser. The amount of skin treated vs. untreated can be controlled by your provider. These patches of untreated skin drastically reduce both side effects and downtime. Even though these procedures have mostly eliminated hypopigmenation and scaring they still produce about 80-90% of the effects that are achieved with full CO2.

I am not as much of a fan of the Fraxel re:store (non-ablative Erbium) because, although it has been proven to improve acne scars, it takes a minimum of 5 treatments and produces less results than 1 -2 treatments of the fractionated CO2 devices (Active FX, Deep FX and Fraxel re: pair).

Between the Active FX, Deep FX and Fraxel re:pair, I like the combination of Active FX and Deep FX better because the technology is less provider dependent and the manufacturer has been making CO2 lasers for skin since 1990.

No matter what your providers tells you expect 2-3 treatment with a minimum of 90 days between treatments for the best results.

Laser

If the question was what is the best laser for treatment of acne scarring?  The answer would unequivocably be the CO2 laser. The reason for this is that the best results are typically obtained with the depth of injury and the extent of and depth of the thermal injury of the treatment. 

CO2 laser creates a great degree of collateral thermal damage and consequently produces the most dramatic results when it comes to correcting acne scarring and/or effacement of lines and wrinkles. The problems with CO2 laser treatment are extended downtime, prolonged erythema (redness), and eventual loss of pigmentation that invariably occurs with this modality. 

This leads to the next topic, a more old fashioned, but tried and true treatment for acne scarring and scar revision.

Dermabrasion

Dermbrasion (as opposed to microdermabrasion) is an older modality which uses a rotating diamond tipped fraise (wheel) to remove the epidermis and portion of the dermis.  The extent of the injury to be corrected is determined by the depth of injury created, which is gauged by the Surgeon's eye and experience.  A depth of injury comparable to CO2 laser treatment is feasible with Dermabrasion. However, several factors make Physicians less comfortable with Dermabrasion than they perhaps should be: 

1. It is a very technically dependent treatment,
2. Wide availability of a variety  of lasers which produce a fairly uniform depth of injury based on the individual laser and the laser settings. 

The aesthetic problem with acne scarring is caused by topographical irregularities, catching shadow and light. The benefit of Dermabrasion is that scars can be selectively planed down to be less noticable.  The benefit Dermabrasion carries over CO2 laser is less thermal injury, far less chance of hypopigmentation (loss of pigmentation), and a much smaller window of erythema (redness of the face). 

Due to its benefits, I incorporate Dermabrasion regularly into my practice for purposes of acne scarring and scar revision.

Acne scars may present with a textural concern (ex: pitted, rolling, boxcar, atrophic) and/or with hyperpigmentation that appears as brown or red in color. The type of scarring will best determine which laser or treatment plan is best for you.  Based on the type of acne scarring, here is what we usually recommend:

• Brown scarring: Q-switched lasers
• Red-based pigment: Pulsed dye lasers

If the scarring presents more as a change to the texture of the skin...

• Mild to moderate acne scarring: Aramis Quantel 

The Aramis Quantel treats acne scars by stimulating collagen under the surface of the skin. There is no downtime with this laser, and it is safe for all skin types.

• Moderate to severe acne scarring: Erbium MicroLaserPeel, which is considered "ablative."

Ablative refers to a more aggressive approach that ablates/removes the top layers of the epidermis. This treatment has approximately 4-7 days of downtime during the healing phase.Anytime an individual chooses an ablative procedure, the benefits will be more apparent. The trade off between treatments that involve downtime and those that don't will be risks vs. benefits. We recommend that you do not invest time and money into a treatment plan that only addresses the scarring until your acne is considered well-controlled over 4 to 6 months.

• For those who choose not to do lasers for hyperpigmented acne scars: Cosmelan (a depigmentation mask worn for several hours) is a good option.

In summary, the following is important information when deciding on the most appropriate treatment plan for acne scars.

• Ablative treatments involves downtime but offers more dramatic, quicker outcomes. Generally speaking, a person requires 3 treatments (Erbium MicroLaserPeel) spaced 4 weeks apart.
• Non-Ablative is safe for all skin types and does not involve downtime. Several treatments are usually required spaced 2-4 weeks apart.
• Your skin type among other factors will determine which laser is safest and most effective for your goals.
• Whether or not your lifestyle permits downtime for healing will also be a factor in your treatments.
• Make certain your acne is well-controlled before focusing only on scarring. Or, use a treatment plan that addresses both concurrently, which is the most common service we offer. It is encouraging to educate yourself on your options so that you have something to look forward to once the acne is resolved and/or controlled and you are ready to move forward.

I believe that the CO2 laser will give the best results for scars of the face. The best of these is the Fraxel re:pair Laser. This uses fractional technology, which has eliminated the risks of further scarring or hypopigmentation.

Nothing is going to remove all the scars, but with one or two treatments with the Fraxel re:pair, it should be significantly better.