Acne scar revision Flashcards
Ice pick scars are less than 2mm in diameter
T
Boxcar scars extend 1mm into dermis
F
0.1–0.5 mm
The 3 methods for treating acne scars are to
Alter the colour
Induce or reduce collagen
Fill the scar
T
Rolling scars may be >5mm in diameter
T
Icepick scars do not extend into subcutaneous layer
F
can do
Post inflammatory hyperpigmentation (PIH) can respond to bleaching agents, light chemical peels, pigment lasers, light sources and fractionated lasers
T
Hyperpigmentation is more difficult to treat than hypopigmentation
F
Hypopigmentation is most difficult
Erythematous scars may improve with time
T
also skincare and vascular laser or IPL
altering the colour is the most common approach to acne scar teratment
F
altering the collagen is
medium and deep chemical peels stimulate collagen while superficial peels reduce pigmentation
T
There are 3 grades of acne scarring severity
F
4 grades
If scars dissappear with stretching the skin is an important discriminator in assessinfg acne scar severity
T
important for atrophic scars especially
If they dissappear its grade 3 if not is grade 4
Discolouration with no textural change is characteristic of Grade 2 acne scarring
F
Grade 1 =
Erythematous, hyper- or hypopigmented flat marks visible to patient or observer at any distance
Grade 4 acne scarring includes atrophy or hypertrophy that is obvious at social distances of ≥50 cm and is not covered easily by make-up, the normal shadow of shaved beard hair in males or body hair, if extra-facial, but flattens by manual stretching of the skin
F
this is Grade 3
Grade 4 is the same but Manual skin stretching cannot flatten it
Grade 1 acne scarring is Mild atrophy or hypertrophy that may not be obvious at social distances of ≥50 cm and may be adequately camouflaged with make-up, the normal shadow of a shaved beard in males or normal body hair if extra-facial
F
this is grade 2
Hypeprigmented scars mainly seen in dark skin types
T
Must advise sun block
Needling devices can penetrate up to 3mm
T
shallow depth needle treatments can do at home without anaesthetic
T
25g needles are used for acne scar needling treatments
F
30g
Dermapen is a vibrating, stamping needle device
T
vibrations make it much less painful
Prophylaxis for herpes simplex is not required for needling procedures
F
Prophylactic antivirals should be used for pts w/ Hx of herpes simplex (Acyclovir 400mg TDS for 5 days)
Needling sessions can be repeated 2 weeks apart
T
Chemica peels are 2nd line to laser techniques
T
TCA CROSS stands for TCA Chemical Reconstruction Of Skin Scars
T
Use 60-100% TCA +/- other techniques (subcision etc) to raise depressed scars
Then often followed by CO2 or Er:YAG laser resurfacing
1927nm non-ablative fractional thalium laser resurfacing can help hypopigmentation
T
or the 1550nm Fractionated non-ablative diode-pumped erbium laser (fraxel SR)
bleaching agents cannot help hypopigmentation
F
use on the normal skin to reduce the contrast
Pigment transfer procedures include minigrafting and epidermal suspensions
T
1550nm Fractionated non-ablative diode-pumped erbium laser (fraxel SR) can be used for macular erythematou scars (grade 1 scarring)
T
moderate (grade 3) rolling scars should be treated with non-ablative resurfacing, microdermabrasion or needling or Dermal or superficial dermal fillers
F this for grade 2 mild rolling scars For grade 3/4 rolling scars use; ablative or non-ablative resurfacing Medical skin rolling Plasma skin resurfacing Dermabrasion Chemical peel Focal dermal filler if localized If extensive- volumetric deeply placed HA, hydoxyapatite or stimulatory agents Subcision BoTox
Fine wire diathermy can be used to treat small papular scars of grade 2 acne
T
also intralesional 5FU
Vascular lasers are mainly used for erythematous scars but may have a positive effect on other atrophic and hypertrophic scar types if they are also present
T
Options for mild-mod hypertrophy (papular) scars include ILCS and/or 5FU and/or silicon sheeting or vascular laser
T
same options for major hypertrophy/keloids
Subcision is treatment of choice for Deep box car scars or Ice pick scars
F
TCA CROSS
Punch excision
Punch elevation if base skin okay
Bridge or tunnel dystrophic scars can be treated with ablative laser
F
excision
Sagging and redundancy due to scar tissue can be treated with rhytidectomy
T
BoTox + fillers are useful for grade 4 atrophic or hypertrophic scars esp in lower face
T
Non-ablative lasers have a less pronounced healing phase at microscopic level
F
more pronounced than ablative lasers
Non-ablative laser thermally denatures the treated skin – pronounced healing phase during which remodelling occurs
T
1540nm Er:glass
1550nm diode-pumped erbium laser (fraxel SR)
1927nm thallium
Ablative lasers have higher risk of erythema and hyperpigmentation
T
Non-ablative Non-fractional resurfacing is comonly used for acne scarring
F
rarely used now
Modest results
Can be used for mild (grad II) rolling scars
Fractional ablative resurfacing good for older pts esp if photodamage and tightening of skin also required – good for all scar types including hypertrophic/keloids
T
Fractional non-ablative laser good for younger pts or where less downtime is required esp boxcar and rolling scars
T
Fractional radiofrequency treatment is radiowaves delivered into skin
T
Fractional radiofrequency treatment can be used for all hypertrophic scars
F
For all atrophic scars - ice pick, boxcar and rolling scars
Fractional radiofrequency treatment has a similar Rx regime and response to fractional ablative (CO2) laser resurfacing
T
causes collagen and elastin formation and remodelling
Microdermabrasion is the technique with the highest risk of hyperpigmentation
F
dermabrasion is
Plasma skin resurfacing is thought to be similar to CO2 fractional resurfacing in efficacy and downtime
T
Dermal Fillers restore volume, firmness, density, elasticity and shape to tissue
T
antegrade injection is typically performed when injecting dermal fillers
F
retrograde injection for isolated atrophic scars (boxcar or rolling) – insert needle at 90 degrees to skin and inject as you withdraw to lift the scar (can use after subcision)
Autologous filler means injecting the patients own fat
T
fat recommended for severely atrophic disease
Cheap, readily available, no risk of rejection or allergy
non-autologous fillers include Purified bovine dermal collagen Hyaluronic acid (HA) Freeze-dried irradiated human cadaveric fascia lata Polyacrylamide
T
Polyacrylamide not recommended as prone to biofilms and late infection
Hyaluronic acid (HA) is a long term filler
F
Hyaluronic acid (HA) causes more sensitization and foreign body reaction than collagen
F
Less
Keloids on the face should be treated initially with kenacort A40
F
start with A10
Intralesional 5FU for hypertrophic/Keloid scars is used at 50mg/ml used neat or diluted 80:20 w/ low strength steroid
T
Use 1ml per session of 5FU and repeat every 2 weeks
May only need 0.1-0.3mls per scar per Rx
Botox is used for ‘movement quiesence’
T
to relax puckered scars in areas subject to a lot of movement
esp on forehead, glabella or chin/lower jaw area e.g. marionette lines, chin
these can become more pronounced with age
Temporary improvement
Works well combined with dermal fillers
Punch excision is used mainly for ice pick or boxcar type ‘punched out’ scars esp if white base, dystrophic or in bearded area
T
For punch excision the punch size must be slightly smaller than scar
F
size must be slightly larger than scar
Punch elevation of depressed scars is contraindicated if if the scar base is poor or the scar is in a bearded area
T
Punch grafting involves replacing punched out scar with a slightly larger non scarred punch from good skin, usually postauricular
T
usually perform laser resurfacing 4-8 wks later
excellent result
In Punch elevation/float – scar is punched but not removed and pts serum injected into base to float the scar up to the level of the surrounding skin
T
usually perform laser resurfacing 4-8 wks later (or dermabrasion)
excision +/- flap repair may be considered for large areas of severely atrophic facial scars
T
It is not necessary to completely remove all underlying cystic tissue when excising large areas of severely atrophic facial scars
F
Be sure to completely remove all underlying cystic tissue which can have wide extensions
Excision can cause cyst reactivation
Subcision results in permanent improvement of rolling scars
T
Several treatments needed; 1-3 months in between sessions
Overpromising results is a pitfall in acne scar treatment
T
Tell pts scars are not removable only improvable
Ensure pts are aware the multiple treatments are often needed and final results cannot be seen for many months
Post op infection after resurfacing is a preventable and problematic pitfall
T
Always think of HSV infection when swelling occurs
Be liberal with antiviral prophylaxis
Must do punch excision, graft and elevation just outside the scar or on the edge
F
Just outside the scar not inside or on the edge
