There are many ways to gauge severity of scars, including classification. Understandably Medicare is super strict on the measurement of scars as in Australia there is currently a subsidy for the management of objectively severe acne scars. This is where it gets tricky as some good peer reviewed articles (International publications), differ from the opinion of Medicare auditors. For example Grade 1 scars are considered as pigment changes, & as such patients with pigment (either PIH-brown pigment or PIE red pigment) are not entitled to a rebate because contour changes are NOT significant enough to warrant a higher (& more severe) classification. Despite good publications reflecting the quality of life index in patients with pigmented scars, Medicare views these as insignificant to cause true impairment & hence no rebate applies.

On the basis of Medicare requirements, I largely agree with the Goodman-Baron classification in the context of contour changes. In fact I think the classification of Grade 4 scarring is too generous (non-distensible scars not coverable by makeup or the growth of beard hair in men at a distance of 50 cm / conversational distances). Personally I feel that conversational distance is > 75 cm. Regardless, this is the grading I use.

There are other ways to assess the severity of scars, apart from objective photographic documentation. Impact on the QOL or Quality of Life is another way of gauging scar severity as are subjective measurements or perception of scarring. I am not in favor of the later as there may be an overlap with BDD or body dysmorphic disorder. Now, if QOL matches with the Goodman Baron score, I will be able to assist. If QOL does not match up with the objective way of measuring acne scar severity, I may not be the specialist for you. This does not mean you can not have your scars treated, it just means that the methods I employ may not be the optimal way to approach your type of scarring. A good guide as to the actual severity of your scarring may involve asking a close friend, family member or partner to assist.

There are other academic methods to assess the success or failure of scar direct treatment modalities, including lesion count. Though accurate if executed correctly, this is not a practical method to assess end points, as some patients may have >300 scars.

In summary, an objective measurement is both practical & realistic, as the goal of scar revision is to give patients the confidence and knowledge that scars may not be perceivable by others at conversational distance. Scar revision, in the method of which I practice, is not designed to pick up scarring at the worst possible lighting at distances that break the conversal barrier. Once again, there is nothing wrong with this assessment (as it is subjective), however as a specialist dermatologist, this is not the end point of which I practice my trade. Of note, there may be other specialists who may take your case on, alternatively I may refer you to my nursing team for fractional lasers, RFM, RF, microneedling & other modalities.

Bottom line? A therapeutic relationship must be established to meet the same end goals & expectations. I will not subject patients with objectively mild scars to surgical procedures or highly aggressive resurfacing.

One of two things, firstly you may have over supportive & super nice relationships – this is understandable, secondly you may have an element of Body Dysmorphic Disorder or BDD. This condition is more common than you think, & can manifest itself with preoccupation with acne scarring & or pore sizing (pore phobia) that is subjectively much worse than objective measurements. Some of the signs & symptoms of BDD include-

Preoccupation with appearance: People with BDD are preoccupied with one or more aspects of their physical appearance, believing that these areas look  abnormal, deformed, or  extremely disfigured (as with acne scarring). People with BDD obsess about the disliked areas, commonly for at least an hour a day (and typically much more).

Insight Regarding BDD Beliefs: Most people with BDD are mostly convinced or completely convinced that they look abnormal or extremely scarred, even though other people don’t see them this way.

Repetitive Compulsive Behaviors: BDD preoccupations fuel repetitive compulsive behaviors that are intended to fix, hide, inspect, or obtain reassurance about the disliked body parts. On average, these behaviors take part several times a day. They are usually difficult to control or stop. These behaviors may include the following:

• Social anxiety & distancing (This is different from real pathology where patients with significant scarring & loss of confidence are socially isolated from the mental impact of objectively severe scars).
• Seeking multiple procedures from specialists or experts in the field (This is different from real pathology where treatments in the past are ineffective in the fight against objectively severe acne scars).
• Preoccupied with methods to cover scars, once again different from employing camouflage to hide objectively severe acne scars.

BDD patients often have poor insight into their condition, ofen refusing the help from family, friends & professionals. I am not a BDD expert, however, I may have more experience in the assessment of acne scars than most physicians.

If you do suffer from BDD, I may elect not to treat you, based upon ethical grounds & my mode of practice. This does NOT mean I will not help you, it simply means I will not employ invasive techniques to treat your type of scarring. I will also offer you psychological & psychiatric help, as management of BDD is beyond my scope of expertise. If you have objectively mild scarring, I will not subject you to unnecessary expenses nor invasive surgical techniques to treat your scarring. Instead I may point you towards ‘lighter’ & more cost effective methods such as fractional lasers.

Fortunately, most cases of acne scarring are superficial & do not require surgical key hole subcision. Simple at home microneedling (0.25 mm Dermaroller from eBay cost $5 to 7 dollars) can improve mild textural changes. Please refer to my videos on safe DIY microneedling.

If you have mild to moderate superficial scars, my clinical nurses can assist you. These nurses have been trained in my methodology of scar revision for the past 6 years. We all employ the same manual methods of TCA application, as well as devices such as Genius RF, Infini RF, Fraxel laser (overrated), CO2 CORE, CO2 Mixto, Erbium Sciton Joule, eCO2, Ultrapulse CO2, Pico lasers, eMatrix, Dermapen, Skinpen, LLEDs, Healite, Kleresca, as well as many other devices & techniques to revise scars. This nurse led clinic is established for patients to get effective treatments for acne scars in cases where there is no Medicare rebate. This provides a cost saving to patients, whilst still having the absolute best access to lasers. Nurse led scar revision ranges from $690 to $1,290, depending on the complexity of revision. For a no obligation assessment with the nurses contact @cliniccutis for appointment times.

There are multiple ways to gauge treatment endpoints, none of which are completely accurate, nor practical in real life. Dermatologists & plastic surgeons often use the 70% rule, namely if we can get 70% improvement at the end of treatment/s this is a realistic goal. I am also guilty of quoting this finish line. Nowadays I have another opinion on end points- skip to the end if you want the short of it, read more if you would like to know the logic behind this.

OK, what does 70% improvement really mean is it-

1. 70% of your scars can not be seen after treatment. If you have 100 scars, you will only be left with 30 at the end?
2. 70% volume reduction of atrophic scars based upon volumetric computation. Namely if you have say a total of 1ml volumetric deficit on your cheek (atrophy), you now have 0.3 ml
3. 70% reduction of pigment, either red PIE or brown PIH
4. Your scars have gone from being visible at 5 meters to now being visible at 1.5 meters?
5. You feel 70% more secure about your scars?
6. The impact of scarring is 70% better?
7. You spend 70% less time thinking about your scars?
8. Only 70% of people can see your scars at conversational distances?

Get the picture? Many ways to quantify 70%, with neither right or wrong answers.

I feel a good end point is to give patients a distance of which they feel or should feel confident at. This is what I call the modified Goodman Baron scale, it is primarily based upon distance. A healthy endpoint is to give patients the realisation & confidence to understand-know & believe that scar revision is successful when other people can not perceive your scarring at conversational distances in normal lighting conditions.