Restoring Acne-Scarred Skin

You now know a lot about what causes acne and about what can be done when it develops. But what if you found this article too late? What if you cystic acne occurred before we had Accutane and powerful antibiotics?

Take a look around and you’ll see dozens of ex-acne sufferers for whom some dermatological miracles came too late. Does that mean it’s too late to help your scarring? Absolutely not!

There are several methods developed in the last few years from which you and your doctor can choose to resurface your scars. Usually a combination of dermatological and plastic-surgical techniques are used.

Many dermatologists and dermatologic surgeons can perform the whole restoration process, so asking your doctor is the only way. Not all techniques will work for everybody, and it’s important that you know what you’re in for.

Take dermabrasion, for example. It’s a major procedure fraught with complications, and sometimes a single dermabrasion won’t do the whole job. Let’s take a closer look.

The Dermabrasion Dilemma

Dermabrasion, or facial planning, is used to recontour and smoothen the surface of the skin. It is a procedure that is not to be taken lightly, since it causes a tremendous amount of temporary disability (weeping, pain, crusting, and possible secondary infection) and some long-term disabilities (several months or longer of altered skin color, sun sensitivity, and possible further scarring).

In this procedure, the dermatologist or plastic surgeon briefly freezes the skin and then sands off the upper layers with a small diamond-coated wheel or brush. This is done under general or local anesthesia.

The sanding is continued until tiny bleeding points are reached in the skin. This indicates that the proper depth for scar removal has been reached. Depending on the type of scarring you have, one such operation may suffice; if the scars are too deep, two operations may be needed.

While there are hazards associated with dermabrasion, such as infection, variation in skin color, and even scarring induced by the operation, it is, in general, a safe procedure when done by skilled hands. It is not always possible, of course, to sand out every scar with the first procedure or even with the second one. You should be sure to discuss all the pros and cons of this treatment with your dermatologist or plastic surgeon.

Very frequently dermabrasions are done in the offices of dermatologists and plastic surgeons. This can avoid the high cost of hospitalization, but the procedure itself is fairly expensive, ranging from $1,000 to $2,500, depending on the surgeon and on the size of the area that must be abraded.

Most demabrasions are full face, because if there is any pigment or texture change in the skin, it’s more desirable to have the entire face look the same.

If the dermabrasion is done to treat active acne (as in sometimes the case) most insurance policies will reimburse the patient. However, even if the policy does not reimburse, dermabrasion, like other costmetic procedures, can function as a tax deduction. Talk to your physician and your tax adviser and health insurance company concerning this before you make plans.

Nothing can restore the skin to its “pre-acne” quality. But dermabrasion, sometimes combined with chemical peels and other rehabilitative efforts, which we will discuss, can result in a better appearance.

If you have significant wrinkling due to age and sun changes, a combined procedure of a facelift and dermabrasion may help you to a greater degree. Often the lax skin of a patient in his or her late forties who has had severe acne as a kid can be radically smoothed by a facelift, even when not combined with a dermabrasion.

Dermabrasion should not be regarded as a cure-all for scarring or any other problem. There are complications with the procedure, and everyone who undergoes it should be fully aware of these complications. Be sure you fully inquire about complications before you undergo any surgical procedure.

Collagen Implants

Advances in scar therapy include the development of Zyderm for injection into scars caused by acne and other conditions. This material is a thick gel produced by chemically breaking up leather into its component parts.

The process makes it very similar to human collagen, the support network for the skin. That’s the part of the skin that actually holds it together, just like the leather in a leather coat. Zyderm was tested with thousands of patients for several years prior to its approval by the FDA and its release in the spring of 1981.

The substance of collagen can be equated to a group of small molecular bricks that cement themselves together under the skin when the correct body temperature and environment are reached. Zyderm should be used only by dermatologists specially trained by the Collagen Corporation.

Some – not all – acne scars respond beautifully to it. The material is injected below saucerlike, gently rolling acne scars, and elevates the center of the scar, thus making shadowing in the scar a lot less noticeable. The scars do not actually go away but their visibility is in most instances greatly reduced.

Treatment with Zyderm for acne scars or any other scars consists of two steps. The first is a test injection: a small amount is injected under the skin of the forearm and allowed to sit in place for a month to detect any possible allergies.

If, after a month, the dermatologist finds no sign of redness or firmness, which might indicate allergy, then a second test injection is usually done up near the forehead hairline. Then, two weeks later (assuming a negative test), the injections of the scars can begin.

There are, however, several groups of patients who cannot be injected with Zyderm. These are patients who have autoimmune diseases, a type of allergic reactions to one or more of the body’s own organs. Chief among these is

rheumatoid arthritis. Others include Crohn’s disease, Graves’ disease, discoid lupus, systemic lupus, Sjogren’s syndrome, ulcerative colitis, Reiter’s syndrome, psoriatic arthritis, progressive systemic sclerosis, polymyositis, and polyarteritis.

Collagen Injection

While the specific number of treatments is determined by the results after the first injection, it is possible to say in general that most acne patients need at least three and sometimes four or five injections to maximally correct scars.

After the one-month waiting period to determine if the skin test is negative, injections can be performed every two weeks until the therapy is completed. Multiple scars are usually treated in a single session. Often, it is done on an entire side of the face in an acne-scarred patient and sometimes the entire facial surface.

There is no limit to the number of lesions that can be treated in each session, but, practically speaking, one or two millimeters of material is the usual dose injected at one sitting if indeed the patient has that many scars to warrant usage of that much material.

Since Zyderm is injected into the skin, there is no reason to suspect that subsequent skin peelings or dermabrasions would affect the treatments in any way. Many dermatologists and plastic surgeons combine procedures.

How long lasting is the Zyderm material? Based on collagen replacement studies, there is no reason to suspect that it may not be present for six months to eight months after the initial injection. In fact, some patients return just for a yearly touch-up with the medicine.

The medicine works best for the types of multiple rolling scars we see after cystic acne, but not as well in the tiny punctuate-, sharply demarcated-, ice-pick-type scars we see in some kids who have had scarring acne.

Complications of Collagen

The main complication, of course, as I have previously mentioned, is allergy to the medicine. While a test injection usually filters out those who are allergic to the medicine, there have been several reports of facial reaction even after negative skin testing.

This involved tender bumps lasting several months. Keep in touch with your skin therapist if you have any problems whatsoever with your injections.

Other possible complications include (rarely) infection and sun sensitivity in the injections sites. Sun sensitivity causes temporary redness. This can also occasionally occur if a patient drinks alcohol after having the injections. In general, it is wise for Zyderm-injected patients to get minimal sun and avoid alcohol for several days after the injections.

In summary, Zyderm collagen implants have become one of the most useful tools in the dermatologist’s arsenal for restoring scarring skin to its normal look. Realize, however, that it does not solve scarring once and for all. It just alters the contour of the skin so that the scarring that is present is less obvious.

In this regard, a patient by the name of Maria had a special type of acne the French call “acne excoriee des jeunes filles.” This means severely picked-at acne of young women. Maria had a tremendously disturbing youth, and as an expression of this discontent she began picking at the few acne lesions she developed as a teenager.

She became so embroiled with her physical appearance that she would actually try to dig out any small imperfection, such as an acne bump, with her fingernail. The result: large scarred craters in place of acne bumps. When she finally paid a visit to a dermatologist, her scars were a quarter of an inch deep, and she had become a virtual recluse.

After a negative skin test, she began a program of biweekly Zyderm collagen implant injections that rapidly filled her craters to the point where shadowing from overhead lights was minimal. The craters themselves would never go away, and the pigment she had scratched out probably would never return, but with minor cosmetic adjustments she was able to restore her social functioning to a more normal basis. Now that’s a cosmetic miracle!

Punch Excision of Scars

Chicken-pox-type scars or acne scars which resemble them have a fairly, sharp edge that makes the elevation of them quite difficult. Often these are best treated by plastic surgical intervention with dermabrasion (“skin sanding”) or actual excision, or cutting out of the scar.

Some skin surgeons prefer to cut out the scar with a small punch biopsy, or cookie-cutterlike instrument, exactly the same size as the scar itself. Then this tiny punched-out piece of skin pops up to skin level, where it is sewn in place.

Later, if there is any irregularity to the skin, a local dermabrasion can be done to smooth it out. This technique is very effective in making these spots look better.

Back Scars

Unfortunately, back scars are the hardest to treat. This is the case where the old cliché, “an ounce of prevention is worth a pound of cure,” actually does apply. The scars on the back are so extensive in some kids that almost no therapy helps.

It seems that the woven, unmedicated acne cleansing pads (like the Buf Puf) used with slightly drying soaps containing sulfur or benzoyl peroxide work best to smooth out some small scars, but really can do practically nothing at this time to help the big sunken scars on the back. Theoretically, Zyderm would work, but small mountains of it might be needed to show significant effect.

You may have noticed from time to time that some acne lesions on the back heal with a nodule or bump above the surface. These are usually reddish at first. They are solid, almost rock hard. These are called hypertrophic scars and are extremely difficult to treat.

Sometimes the peeling slush treatment with carbon dioxide, made up by mixing acetone with crushed dry ice, or a spray-freezing treatment with liquid nitrogen does help in combination with injections of cortisone right into the scars.

Various types of cortisone are used for these shots. (Note: These treatments are to be administered only by your doctor; they are never to be attempted by the patient!) It’s these terrifically damaging scars that we hope the new retinoid drugs will help avert in the future.