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PST 002: The Ruthlessness of Acne Scar — Read the Transcript

February 21, 2018

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Welcome to Plastic Surgery Talk with Dr. Stephen Mulholland, brought to you by SpaMedica. Hello and welcome back. Dr. Stephen Mulholland, plastic surgeon, here in Toronto Canada, with our podcast webinar series. This podcast and webinar is on acne scaring, a very, very common phenomenon and unfortunately a tragic one as well, because it can snatch away from you in one inflammatory process that beautiful God-given skin that you had as a young child.

You enter into adolescence, or sometimes even into adulthood, without acne scaring and certain hormonal changes occur that create these inflammatory lesions. If the lesions are deep enough and the inflammation from the acne bacteria is aggressive enough, you’ll get these cystic developmental lesions that then when they resolve, can lead to an indentation or a crater. And there’s different types of acne scars. You can get the rolling hill acne scar, which is reducible and much more favorable to treatment. You can get icepick acne scars. And you can get what are called boxcar, or more rectangular acne scars.

Each of them respond differently to different treatments. The good news is for acne scar sufferers, we have never had better technology to treat them. The bad news is, even at a place like SpaMedica, the largest private laser center in Canada with over 60 different lasers that I could potentially use to treat your acne scars, I can’t create 100% scar removal. It’s always going to be some improvement, and the improvement depends upon the type of scar you have, how early we treat it, and what technology we use.

So, what creates the scar is the inflammation or the acne bacteria and the raised lesion. It gobbles up and inflames the normal skin, and when everything resolves the normal skin is gone and you’ve got a healing wound. And the healing wound leaves a depression. And so, our job is to get rid of the active acne and set up the opportunity to treat the acne scars, themselves.

What are the various degrees of acne scaring? Well, one of the classifications is mild and severe, and everyone knows what that is. Mild scaring, very superficial texture, rolling hill type of acne scars, generally some fractional resurfacing technique, or laser technique, or radio frequency technique, one or two treatments can give a 70-80% reduction. And those are the fortunate individuals who have mild acne scaring. And that’s easily treated with some of the technologies we’re going to talk about in the podcast today.

Then there’s severe acne scars. Severe acne scars are deeper, they are thicker, there’s more abnormal collagen, scar tissue deposition, and you can divide the severe acne scaring into clinical subtypes. The rolling hill acne scars with more reducible edges, the very deep but narrow-necked icepick scars, they’re very hard to treat. And the thick rectangular boxcar acne scars. And often these different clinical subtypes live together in the same cheek, the same forehead, the same back or chest.

So, you can get acne scaring on the face, the chest, the back, any area where there’s thick sebaceous skin. And you can have mild or severe. You can have boxcar, icepick, or rolling hill, all admixed in the same area. So, it’s very important that you see a clinical specialist, a private physician usually, who’s going to be a plastic surgeon, a dermatologist, maybe a facial plastic surgeon who has a lot of experience with treating acne scars, and has the technology to address the scaring tissue itself. Remember, don’t start treating the scars until you’ve settled down the active acne. If you actually treat scars where there’s active acne, you can make the active acne worse and create more scaring. So, step number one, get control of the active acne. Step number two, when all is quiet address the scars.

So, how to first get rid of active acne, because that’s step one. Active acne is usually red inflamed skin, little red bumps, in mild acne called maculopapular eruptive acne, or very big thick inflamed nodulocystic acne that leave the biggest scars. Sometimes you have both types in the same cutaneous envelope, or skin place like the cheeks, temples, upper chest, back, these are the common areas. So, first you gotta get the active acne under control.

How do you do that? See a medical specialist. You can’t always do late night television mail order catalog treatments, you have to get at the heart of it. Nowadays, many dermatologists will start with an oral antibiotic and a topical keratolytic like salicylic acid, benzoyl peroxide, those are the typical starting points. Once that fails, generally we’ll go to blue light laser treatments with topical aminolevulinic acid, intense pulse light photo facials, ultrasonic microdermabrasion, ultrasonic removal of the sebaceous plugs, and we treat the acne at multiple levels.

Clean up the red and the inflammation with intense pulse light photo facials, use blue light to target the acne, as well as topical ALA, aminolevulinic acid, get rid of the sebaceous plugs with ultrasonic micro-dermabrasion, or using the Isolaz for blue light or blue light laser sources. And we usually can combine all of those together in an acne skin care program and in over six to eight weeks, get the active acne quiet. Once it’s quiet, we can deal with the scaring.

Okay, step one’s done, the active acne is controlled, finally, but now you’ve been left with the scars. The scars can be white or they can be pigment inside the scar and have a dark base to it. So, we want to treat the scars with fractional technologies. Fractional radio frequency resurfacing needle technologies, fractional laser technologies, under the skin subcision or radio frequency heat subcision, sometimes soft tissue fillers in the skin to plump up the skin with particulates like Articol, or Radiesse, or sugar gels like Restylane and Juvederm. And we often will combine light based treatments like photo facial, intense pulse light, pulsed dye laser, the picosure laser, to remove pigment from the face of the scar.

So, we can use injectables, we can use biostimulants like platelet-rich plasma to build up new collagen, we can use lasers, we can use fractional laser devices, which treat the skin proportionately. All of these things are designed to build up collagen, smooth in the depth of the acne scar, and improve the quality, color, and tone of your acne-scarred skin.

Fortunately, with social media nowadays and reality shows, we are actually seeing and witnessing the active treatment of well-known people, iconic figures, like Kendall Jenner, who had inflammatory acne as a young gal and underwent some laser treatments using a Y-A-G, called a YAG laser, in low energies to settle, along with skin care and other topicals, the active component of her acne. She was fortunate, it didn’t leave a lot of scarring. But had she not gotten that in the early phase 1 of the inflammation, and let it go, it could’ve led to aggressive scarring.

What if you do phase 1, like a low-level light, laser, topicals, you’re seeing a plastic surgeon or cosmetic dermatologist, and it’s just not working? They might take your treatment to DEFCON 2, where we actually try to turn off the sebaceous oil secretion in the very home where the acne bacteria live. So we turn off the sebaceous gland with a drug called vitamin A, or Accutane. Now, the problem with Accutane, it has a lot of side effects. It has to be prescribed by medical specialists. And in general, we start with very low-dose Accutane first, to minimize the side effects. Very important that you get certain blood test and liver tests monitored. You would never start with Accutane, but faced with the really horrific tragedy of permanently scarred skin from acne scars, Accutane, under medical supervision, is still a good option for DEFCON 2. Once you get things healed and it’s resolved, it’s easy to maintain acne-free skin, is getting the treatment to control it in the first place.

What are some of the urban myths around acne and acne scarring? Number one urban myth: “I eat too much sugar.” Completely unrelated to sugar intake. You see lots of your friends consuming diet sodas, sugar sodas, having a terrible simple carbohydrate diet, with perfectly beautiful skin. You can see vegans who eat nothing but complex carbohydrates, tofu, and soy, with terrible skin. So, it’s not related to the diet as much as it is your genetic risk around the oil glands. And if you have a genetic risk for oily skin, you have blackhead- or whitehead-prone skin, and you have a history of adolescent acne in the family, you’re likely going to get it regardless of the diet.

The second urban myth is that, “I’m not washing my skin.” Generally, I’ve found my acne prone patients to be the most hygienic of all the patients. They scrub mercilessly on their skin. Most acne patients spend most of their early and late evening hours cleaning, cleaning, cleaning. And so, it’s not that you’re not cleaning it enough, it’s that we are not getting the right treatments to the home in the sebaceous gland, at the base of those hair follicles, and where the sebaceous glands live, and you can’t clean deeply. You’ve got to use other techniques to get there.

The next urban myth is that somehow, a tanning bed, a UV light is somehow going to provide long-term control and improvement for your acne. It’s not. All we’re doing is adding UV light, which tans the skin slightly, and hides the acne and acne scars you have. It’s not providing any inherent improvement. In fact, over time, sun exposure, UV light exposure, will age your skin prematurely, cause laxity, and make your acne scars look worse. So, you’re only temporarily hiding that acne scar with the UV light. UV light may have some very, very temporary improvement in an immediate inflammation around acne from the UV light, but the long-term deleterious side effects of sun exposure are just not worth it.

The last is that some simple, quick fix like Clearasil, or some benzoyl peroxide is gonna solve the problem. In general, very mild adolescent or early onset adult acne can be resolved with a little benzoyl peroxide and salicylic acid. But if you have true medical acne, nodular, cystic, or inflammatory, you’re going to need to see a medical specialist and take it to prescriptive doctor-strength treatments, or laser driven treatments, or both to get the results you want. It’s not going to be an over-the-counter or late-night infomercial solution.

How to choose the right medical specialist to treat your acne? Well, you want to find a medical specialist that’s a licensed physician in your jurisdiction, state, or province, and territory. You want to make sure that they have acne experience, that on their website, they list acne as one of their active treatment interests. Make sure they have a comprehensive acne program, that they have prescriptive opportunities, they have skincare opportunities, they have microdermabrasion, they have lasers that can treat the redness, they have lasers that are blue light driven that can treat the inflammation, they have fractional devices, radiofrequency lasers, that can treat the active inflammation.

Make sure they have good before and afters, testimonials of patients that have had acne with a good result, that they have a good social media presence, that their rating sites like Google plus, Facebook, RateMD, RealSelf, are proliferated with good reviews. There will be a few bad if it’s a busy practice, but predominantly very good ratings. And some ratings from acne patients, and maybe the doctor’s even commented on blog posts about their passion for treating acne skin. These are the features you should look for in a good acne specialist. And then you should source out two or three, interview them, and pick the clinic that has the most features of that list that fit your goals, tactics, and strategies, and of course, price point.

Again, thank you for joining me, Dr. Stephen Mulholland, here in Toronto Canada. I want to end by asking you to share this on all of your social media channels. And follow us everywhere at SpaMedica.

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