What's best treatment for acne scarring? Thinking about CO2 but scared of pigmentation (Photo)

Question

Ive been suffering with acne scarring for 20 years now. Ive done numerous dermapen and prp. Also one rf microneedling. I have seen result but still lot of scarring. Im thinking about co2 but scared of pigmentation.

Nelson Lee Novick, MD · Answer

I have been treating acne scars for decades. Dermapen would not have been expected to be particularly effective, since microneedling is best for treating superficial, surface texture and color irregularities and is not useful, as you found out the hard way, as a monotherapy for deeper acne scars. PRP is a relatively expensive and heavily marketed & hyped modality, but the hard science to support its routine use is unfortunately lacking. So, no surprise that this modality was not really effective for you. C02 laser, like dermabrasion, runs the risk, especially in skin of color (SOC), for the post treatment development of pigmentary (both hyper or hypopigmentation) problems that can be long-standing or even permanent. Subcision, on the other hand, is a treatment technique that I have personally been using since 1994, for elevating and smoothing boxcar and rolling scars, that has a proven safety and efficay record overall and in SOC. TCA CROSS, another relatively inexpensive and simple technique, with an over two decade record of safety and efficacy for the treatment of ice pick scars, likewise is appropriate for treating SOC. So, it would be wise to consult an experienced, board certified cosmetic dermatologist and exercise a healthy dose of skepticism about being offered any more "bells and whistles" energy or light-based devices or faddish treatments. Best of luck.

Monika Kiripolsky, MD · Answer

Hi Royasami!
You would be a great candidate for the CO2 laser +/- subscission for your acne scarring! But, due to your more olive skin tone, it would be absolutely essential to be on several weeks of pre-treatment (prior to the laser) with prescription-strength topicals like hydroquinone and retinol to minimize the potential for hyperpigmentation after the procedure. You should also go to someone who is not only board-certified, but who has also done a fellowship in lasers so that your doctor is well-versed in the appropriate laser settings to use to yield the most effective results in terms of minimizing your acne scarring (while also minimizing the potential for complications). 
Hope this helps!
Dr. Kiripolsky

Raffy Karamanoukian, MD, FACS · Answer

Fractional CO2 laser is an excellent tool for skin rejuvenation in our center in Santa Monica. We use the fractional multi-depth ablative approach to help resurface the skin, recontour acne scars, improve incisional plastic surgery scars, and reduce surface irregularities from skin tone to dark pigmentation. Our approach utilizes a multi-depth approach that targets melanocytes in the epidermis and collagen fibroblasts in the dermis. This approach can be combined with a TCA Peel in a process known as a sapphire peel. Fractional laser is excellent for acne scars and contour scars in the skin. Patients are advised to undergo skin protocols with Melarase creams before and after treatment to help reduce pigmentation. Melarase AM, Melarase PM, and Melapads can seriously improve surface sun damage and UV related pigmentation. After the laser, we expect redness for a few weeks as the skin improves. PRP and Hydrafacial enzyme facials can further improve skin quality after fractional co2.

Best,
Dr. Karamanoukian
Realself100 Surgeon

Best, 
Dr. Karamanoukian 
Realself100 Surgeon

Jason Emer, MD · Answer

"​Acne scars need a combination approach for long-term improvement. Everyone has a unique pattern of acne scarring, and most people have various types of scars, so we create a tailored treatment plan for each patient. We often use:
- Injectable fillers like Bellafill and Sculptra (with or without subcision) for atrophic, indented scars. 
- Subcision for depressed, tethered scars. 
- Vascular lasers like Yellow laser, Aerolase, excel V, BBL, or IPL for redness or thick acne scars. 
- Lasers such as Fraxel, Erbium, CO2, Halo or fractional radiofrequency (Venus Viva, Skinfinity, Morpheus, PiXel8, Fractora, Intensif microneedling RF) for textural issues and superficial scarring. 
- TCA CROSS and punch excision for deep ice pick scars and narrow box car scars.

All lasers are combined with microneedling/PRP to improve the results and accelerate your healing time. Keep in mind that a personalized combination treatment by an expert physician will give you the improvement you're looking for. I recommend getting a formal evaluation with an experienced cosmetic dermatologist and acne scarring expert. Best, Dr. Emer. ​"

Milan Shah, MD · Answer

The best treatment for acne scarring can depend on the type and severity of the scars. CO2 laser resurfacing is an effective option, but it does carry a risk of pigmentation issues, especially in individuals with darker skin tones. You might want to consider alternative treatments like microneedling, chemical peels, or fractional laser treatments, which have shown good results with less risk of pigmentation problems. Consult with a medical professional to discuss your specific case and determine the most suitable treatment for you.

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