Treating Acne Scar in Darker Skin At A Glance
- Best Results3-6+ treatments
- Treatment Recovery5-6 days
- Procedure Time5-40 min
- Skin SpecialistNurse, Davin Lim
- Duration of ResultsPermanent
- AnaestheticNumbing
- Back to Work1-5 days
- Cost$-$$$
Acne Scars In Darker Skin
Acne scar treatments in darker skin patients pose unique challenges as skin of colour reacts differently compared to lighter skin. Hyperpigmentation is common, & in most cases, part of the healing up process. Precise peel concentrations & lasers will decrease unwanted side effects.
FactsFacts On Treating Acne Scars in Darker Skin
- The biology of ethnic skin is different compared to lighter skin types
- Skin pigment production namely melanogenesis is more brisk in ethnics
- Additionally collagen remodelling cells called fibroblasts are more active
- Parameters & devices selection is important to mitigate side effects
- Pico lasers, insulated RFM & correct methods are required to give good & safe results
- Scar revision may take a little longer in ethnic skin types based upon the above factors
Acne Scars In Darker Skin
The biology of darker skin types is unique. Ethnic patients naturally have more melanin or pigment. Any breach of the upper layers of skin, whether it be lasers, microneedling, peels, surgery or energy devices, has the potential to produce more pigment. This is called post inflammatory hyperpigmentation or PIH. It is thus important to predict the duration of PIH, & importantly find solutions to mitigate or reduce the duration of PIH.
PIH is part of the healing process in this patient group. It can last 10 days all the way to 6 months or longer. Hence the aim of treatment is to balance out effective methods, but also decrease the duration of PIH.
The second factor in acne scar revision in ethnic skin types, is based around dermal responses, in particular the cells that produce collagen, namely the fibroblast. Darker skin patients have a brisk collagen response, hence why keloid & hypertrophic scars are more commonly encountered. Treatments must account for this biological response. This mitigates unwanted scarring.
What scar patterns are unique in darker skin patients?
Acnes scars are more severe in darker skin types due to several factors.
Firstly darker skin patients are more prone to scar patterns including fibrotic papular pebble stone scars on the nose, & chin. Additionally ice pick scars are more common.
Secondly it has to do with optimal transmission & reflectance of light. Darker skin absorbs light, lighter skin reflects. That is why dents on a white car door are less noticeable than on a dark car door. The darker the skin type, the more noticeable scars are. Volume deficits may be equal but perception changes with direct & strong lighting. Tangential lightning however takes away the colour bias.
What procedures are best for darker skin types with acne scars?
Acne scar revision is still performed in similar ways, bar two exceptions-
Firstly fully ablative laser resurfacing has to be performed in caution. I do employ both CO2 & erbium lasers, but the depth has to be shallower in darker skin, otherwise PIH may be long lasting. Post inflammatory hypopigmentation (loss of colour) is even more disturbing.
Secondly deep focal & segmental peels require a more conservative approach- once again it is hypo not hyperpigmentation that is more serious
All other revision methods including fractional laser, microneedling, excision, punch excision, elevation, dermal grafting, surgical subcision, RFM, dermarolling & pigment specific lasers apply, albeit different settings.
Why is insulated microneedling important in darker skin patients?
At Cutis Dermatology we mainly use energy based microneedling as this remodels collagen better than normal non energy based systems like Skin Pen & Dermapen.
Energy based microneedling (also called RFM or radiofrequency microneedling), can be classed as insulated or non-insulated needling. Insulation is paramount for increased safety in darker skin patients. Examples of insulated RFM include Genius, Infini & Intracel RFM. Insulation protects the upper parts of skin known as the epidermis, whilst allowing controlled heating of the dermal layers of skin, where scars reside.
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What does Post Inflammatory Hyperpigmentation mean?
PIH means darkening of the skin. This is part of the healing up process for patients with darker skin type (Asian, Middle Eastern, Islanders, & many more ethnicities). In some cases, PIH is an unexpected side effect. It is very important to predict & differentiate between expected outcomes & side effects.
For example, skin colour changes following TCA CROSS or Paint are expected in almost all Ethnic skin types. This generally fades in 4-12 weeks. This is in contrast to lighter skin types where by skin colour change lasting more than 2 weeks is an unexpected result, & hence a side effect.
What lasers & devices do I employ when treating darker skin types?
Treating acne scars in darker skin patients add another layer of complexity. Laser settings must be exact. I use specific short pulse duration erbium & CO2 lasers, in addition to precise pico lasers. I also employ insulated impedance controlled RFM or radiofrequency microneedling.
In many cases, lasers are often adjunctive treatments, as I prefer manual methods such as surgical subcision & deep focal peels.
The challenging aspect of this patient is the skin type (5)
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👉👍🏻Pros of this acne scar pattern: relatively superficial mix of broad boxcar, boxcar, pick & the odd ice pick. The biggest advantage of this patient is the absence of active acne, hence we can concentrate on revision & not chase our tail
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🔫Treatment: erbium fully ablative + fractional CO2, recovery 6 days
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🖐🏽Pigment or post-inflammatory hyperpigmentation is expected, as noted in this picture. PIH can resolve with usual pigment faders, we can expedite the process with pico lasers
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🎥B+A: after photo taken in march, she will finish the cse of pico in a few weeks, final results next month💯
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😎Davin Lim
Dermatologist
Brisbane, 🇦🇺
#acnescars #acnescartips #acnescarremedy #acnescarcure #scars #drdavinlim #darkskin #scarremovaltips #scarremoval #cutisdermatology #laserresurfacing
Asian skin type 4. Box car, ice picks, mild rolling acne scars
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🔬Skin Science: Treat scars according to classification (histological level of scarring) & patient factors, most importantly skin type. This patient has skin type 4, The downside of ethnic patients is that scarring is more severe, more apparent (depth for depth), as darker skin absorbs light, fair skin reflects, the brisk response of melanocytes to energy devices & peels, the brisk response of fibroblasts; think #keloids & hypertrophic scars BUT… (every cloud has a silver lining) ethnic skin has a thicker dermis AND has a greater potential for neocollagenesis
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👉This patient: had TCA Paint, CO2 fractional & finished off with pico lasers. With 4 sessions of Picoway, we managed to treat the PIH from other treatment modalities and at the same time improve skin texture, including enlarged pores
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👍🏻Tips: Above ALL THINGS, control active acne, no matter what. Your acne scar revision process will be much more efficient & effective. Share if you find this useful
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😎 Davin Lim
Dermatologist
Brisbane🇦🇺
@drdavinlim
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#subcision #rollingscars #acnescars #acnescarrevision #acnescartreatment #fraxel #fraxellaser #acnescarremoval #brisbanedermatologist #dermalscience #acnescarring #davinlim #drdavinim #acnescartreatment #acnescarcure #dermatologistbrisbane #co2laser #laserresufacing #picoway
Basic acne scar revision concepts
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👉Real life: Is not that simple. Scar signatures vary considerably even within patients.
Scar morphology changes with procedures. Classification however is a great starting point
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🛬Many doors to the same destination: In most cases the rules are not set in stone, & there are various methods to treat each scar type. Add to this the differences in devices & skill sets of operators. If all things are equal, there is a marked variation between each patient’s regenerative & remodeling potential. Furthermore age related atrophy plays an important role in acne scar revision
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👍🏻It’s much more complex than matching scars to procedures, but it is a step in the right direction💯
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😎Dr Davin Lim
Dermatologist
Brisbane 🇦🇺
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#acnescar #scarrevision #acnescartreatment #acnescarcure #icepickscars #drdavinlim #brisbanedermatologist
Skin Type 5, PIH still evident at 3 months
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👉Scar type: mixed deep box car, rolling, pick, ice-pick, atrophic. Skin type rate limiting factor
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🔎Solution: I still employed erbium fully ablative, followed by CO2 fractional. The patient had the understanding that PIH is inevitable if I am chasing scars. PIH treated by my nurses with Picoway. Will take another 3 mtns to resolve
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👊🏻Concept: Trade scars for PIH 2-8 months. No trade, means taking 4-5 times longer to finish the job💯
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#scars #scarrevision #acnescars #scartreatement #davinlim #dermatology
#nomorescars #co2laser #laserresurfacing
This job took awhile as acne was largely uncontrolled. The biggest leap was when she controlled her acne 5 months ago
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🔬Skin Science: This is one of the more challenging jobs, skin type bordering on 5. Deep polymorphic scars, atrophic rolling, box car as well as focal areas of fibrosis (central cheeks, hypopigmented atrophic)
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👊Methods: Subcision, high power but low density CO2 plus RF microneedling, TCA paint to well demarcated scars. Pico recently for PIH & textural remodelling
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👨🏾🦲PIH is universal if surface treatments are conducted. This also applies to high powered RF microneedling (Genius RF, Infini RF, Morpheus 8 RF). Pico lasers are useful for adjunctive treatment, along with the usual tyrosinase inhibitors & SPF as primary methods to prevent/reduce/treat
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🏡Take home: control acne, during or prior to scar revision. This means ABSOLUTE control, you will go further, faster. Neocollagenesis ain’t efficient if your immune system is fighting off c.acnes next to your scars
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#acnescars #dermatologist #scarrevision #fractionallaser #dermalscience #dermatology #scartreatment #acnescartreatment
Can I perform treatments that do not give skin colour changes?
Yes. I can use a particular laser, peel or device to markedly reduce the chances of hyperpigmentation & skin colour changes. The flip side? Scar revision procedures may take three to six times as long to complete. In some cases it may take up to three years to finish a job.
For patients who are risk averse to pigmentation, procedures such as microneedling, low energy lasers, subcision, & low strength peels are possible. Remember, effective scar revision in darker skin types is always a trade between speedy results & the probability of skin colour changes.
How long will it take for pigmentation to fade?
Post inflammatory hyperpigmentation can take up to 18 weeks to fade completely. There are many things we can do to speed up recovery & fade pigmentation. See below.
What things can I do at home to help pigmentation fade?
The most important thing to implement (even before any procedures) is to develop a good habit with sunscreen. Regardless of sun exposure, apply a sensible amount of sunscreen at least twice a day.
Skin care ingredients can help with pigmentation. Hydroquinone products such as Superfade applied nightly to the dark areas can help. Azelaic, ascorbic & retinoic acids can do the same. Botanicals such as bearberry & licorice root inhibits pigmentation formation.
What are the things we can do to speed up the process?
Before any procedure my clinical team & I will warn you about the expected outcomes & potential side effects. Remember that with some procedures such as laser resurfacing & deep chemical peels, skin colour changes are part of the healing up process.
If post procedure pigmentation is stubborn we employ various lasers & clinical strength skin care to help speed up the process. Lasers include pico & nano Spectra. Gentle chemical peels can also help. In some cases I will prescribe specialist strength pigment faders or compounded prescriptions that include arbutin & cysteamine.
How important are skin care products?
Precise skin care can markedly reduce the chances of prolonged skin colour changes. The foundation of all management is sunscreen. Remember even if you don’t go out in the sun, simple daily tasks like doing the shopping, going to work & even sitting next to a window allows UV on your skin. Thus, it is imperative that you develop a habit of twice daily application of sunscreen before any treatments.
Post procedure my clinical team will guide you through skin care ingredients that can help prevent skin pigmentation & amplify the gains of procedures.
Davin’s Viewpoint on treating Acne Scars In Darker Skin
The fundamentals of acne scar revision still apply to darker – ethnic skin, namely applying a method to revise the pattern of acne scarring. It is just the execution of principles that may differ when treating skin of colour. As a rule, for skin type 3+ or darker, expect transient skin colour changes, namely hyperpigmentation. Essentially patients trade up, namely trading deep scars for temporary hyperpigmentation that will fade over a period or weeks. No trade? Still can be done, but it may take two, three or even five times as long.
For darker skin patients, I still perform CO2, erbium & deep peels. I do however adjust the parameters – namely less passes, short pulse duration, lower density, longer wavelength (esp for pigmentation). Pico lasers are handy for PIH however they do not give good results for atrophic scars.
The flip side of ethnic skin? A more vigorous fibroblastic response biased in ethnics, can give accelerated results, especially for deep tethered scars, providing of course, background inflammation is quiescent. This means absolute control of background acne.
