- Best Results9-12 months
- Treatment Recovery1-10 days
- Procedure Time60-120 minutes
- Skin SpecialistDavin Lim
- Duration of ResultsPermanent
- AnaestheticBlocks & numbing
- Back to Work0-8 days
White & Hypopigmented Scars
White scars, known as hypopigmented scars can be due to acne, burns, drug use & trauma. They can be challenging to treat. The focus is to get your pigment cells to produce more melanin. Lasers, topicals, microneedling & melanocyte surgical transfer are methods to achieve this. The highest success is seen in autologous surgical melanocyte transfer via micrografting.
FactsFacts on treating white & hypopigmented scars
- If pigment cells are viable, simple microneedling can be effective
- Microneedling is best combined with creams that stimulate melanin production
- Lasers can be used to increase pigment production in some cases
- Micrografting gives the most predictable results as it transfers pigment cells
- Phototherapy after melanocyte transfer accelerates pigment production
- Cosmetic tattooing can give great results, if performed correctly
- Autologous cultured melanocyte transfer & stem cells are several years away
- ReCell can be effective in some cases
What is the concept of Hypopigmented Scars revision?
Logically scars are contour changes, color changes, or both. Fix these two variables and the scar is improved. For hypopigmented-white skin scars, the aim of treatment is twofold.
- Firstly get pigment back within the scar (re-pigment white areas)
- Secondly, reduce the contrast of surrounding skin.
Hence to revise the look of scars, we need to concentrate on the above factors.
Why are white scars hard to treat?
White or hypopigmented scars have a lack of pigment, this means that pigment cells known as melanocytes are either low in number or non-existent. In order to improve pigment, I must either transfer new melanocytes or awaken sleeping cells in the scars. This is the only way to get pigment back.
Melanocytes account for one in thirty-five cells that form the basal layer of skin. Their job is to produce pigment. Pigment packets are then transferred to the keratinocytes. In hypopigmented or white scars, the number is reduced. Hence pigment is either greatly diminished or non-existent.
How to reduce the contrast of surrounding skin?
Firstly, reduce tanning. Simple sunscreen twice a day to the unaffected areas will reduce pigment in these areas. From there you can add AHAs like glycolic or lactic acid creams & serums. Lasers including pico, fractional Fraxel, nano-dermal toning & other can be effective. Chemical peels with AHAs can also reduce contrast.
What is my preferred method of treating white/hypopigmented scars?
My preferred method is micrografting with autologous melanocytes. This is an involving treatment as it requires surgery with healing times. Micrografting is successful in most, but not all cases.
This procedure transfers pigment cells from a donor site (most commonly the inner arm, upper thigh or buttock) to the recipient site (hypopigmented scar). This is a form of autologous cell transfer.
In more detail-
- A sliver of skin including melanocytes are harvested by hand using a blade.
- Donor site harvesting is painless as I use local analgesia
- Pigment cells are processed into small units
- Recipient site is prepared with either manual dermabrasion or laser
- Cells are placed on the hypopigmented scars
- Pigment cells populate the recipient site over the next 10 days
- Pigment starts to develop at week 3
- Maximal pigment is achieved at 9 to 12 months after the surgery
What is ReCell, & is it effective for white scars?
ReCell is marketed as a spray on skin. It uses your own skin cell as a donor & transfers melanocytes to the areas of hypopigmentation. A special enzymatic process breaks down the donor skin into small pieces. This is then sprayed or painted on to the affected sites. I normally get a team of specialists based in Western Australia to assist in this procedures.
I have used ReCell for the past 7 years, I prefer micrografting manually over processed skin as the results *in my hands* is better. Manual micrografting is more cost effective for the patient.
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What is bimatoprost?
Also known as Lumigan 0.03%, this comes as drops. It is used to increase the length of the eyelashes, but it can also stimulate pigmentation. Bimatoprost can be used after microneedling. See the DIY section for more information.
In Australia, bimatoprost requires a prescription (from any doctor), you can be resourceful & find it online.
What is tacrolimus?
This is a calcineurin inhibitor. It reduces skin inflammation, however in the context of white or hypopigmented scars, it accelerates melanocyte migration. In some cases I will prescribe this cream, along with phototherapy. You can be resourceful & source it online. It is also known as Protopic. See below.
How can lasers improve pigmentation?
The theory behind lasers is three-fold.
- Enables transepidermal delivery of pigment stimulating creams. As the pigment cells are in the epidermis one does not need a superhero deep laser to get to this level. My go to lasers are thulium 1927, & CO2 fractional
- Lasers stimulate germ cells in the area to differentiate, hopefully to melanocytes. The latter produces pigment.
- Lasers can stimulate existing cells (low in number) to wake up and produce pigment. Think of it as iatrogenic post inflammatory hyperpigmentation.
How many laser sessions will you need?
About 3-8, it really depends. If you have mild hypopigmentation, 1-3 sessions will do. For more extensive areas, additional sessions may be required.
Lasers can stimulate melanin production via increased absorption of chemicals that stimulate these cells. Addition of medical phototherapy can compound pigment production.
Do I use microneedling for white scars?
Yup, sure do. Even though I have over 30 lasers at my disposal, sometimes simple treatments are the best. I prefer microneedling with a dermaroller over pen-stamps. Why? Because I have been microneedling for two decades and old habits die hard. My nurses like derma pens, but for home use, a dermastaper is safer.
The most important concept to understand is that longer is not better (that’s what he says). The pigment cell is in the basal epidermal layer. Hence with adequate pressure, 0.1 to 0.2 mm will get you there. Microneedling is designed to deliver topicals & (in theory), release growth factors, cytokines & chemokines to stimulate pigment cells.
For microneedling, you may require 6-10 sessions for optimal pigmentation (that is if you have viable melanocytes in the first place).
What are DIY treatments for white or hypopigmented scars?
Not everyone has access to a dermatologist. Home DIY treatments can be effective in a small number of patients. The most important aspect of home remedies is safety, so I will only address sensible treatments. Try this if you are desperate, can’t see a dermatologist or cannot afford treatments at this moment in time.
- Buy yourself a dermastamping tool from Amazon or eBay. Stamps are preferred compared to skin rollers. Look for 0.1 to 0.2 mm lengths. Do not go deeper.
- Get some Latiesse eye drops (bimatoprost). Apply 3-10 drops within 10 minutes of microneedling. Cover with gladwrap. Do this twice a week.
- Another option is to get some tacrolimus (Protopic), apply this to the hypopigmented areas on the days of your microneedling. If you are using 0.1 mm needles, you can do this up to twice a week.
- Home UVB light sources can be helpful. They are not as powerful, nor as accurate as clinical sources.
What is phototherapy?
This is a medical treatment that delivers special light therapy to the areas of hypopigmentation. It is vastly different from usual light sources as it concentrates one band of light (UVB at 311 nm). This can stimulate pigment cells to increase their output of melanin.
Phototherapy is under Medicare. Patients undergo 2-3 sessions per week. It can take weeks to months for optimal results. This treatment should be considered as adjunctive therapy after surgical procedures including micrografting, punch, suction blister & ReCell treatments.
How many treatments will I need?
If you are undergoing laser re-pigmentation or microneedling, you will require between 3-6 sessions over the course of 4-7 months. For surgical procedures, I try to complete the treatment in one session,
In the context of phototherapy, between 4-9 months is ideal.
Can cosmetic tattooing reduce the appearance of scars?
Yes. Cosmetic tattoos are different compared to traditional tattoos. Medical tattooing uses different pigments. They are semi-permanent & frequently require touch ups every 12-24 months. Finding a good medical tattooist who can colour match is essential for a good result.
Note: sun exposure will fade your cosmetic tattoo & also increase the contrast between pigment.
What are meth - ice scars & how do I treat them?
Methamphetamine use can give a unique scar pattern, namely gouged out hypopigmented scars. This is because with ice use one can experience hallucinations & altered sensations (creeping, crawling, itch), a person can pick, gouge & scratch without feeling pain. I see at least one of these scar patterns every few weeks.
The burden to the patient can be significant as it reminds them of the days of addiction. Most ex-addicts would want these removed to reduce the physical & mental anguish.
Meth-ice scars can be challenging to treat as they have elements of atrophy (divots) as well as decreased pigmentation. I employ one of a few strategies to reduce scarring-
- Blend in the surrounding skin with lasers (creates less contrast)
- Dermal grafts or fillers for atrophic scars
- Fractional lasers & pigment stimulators for hypopigmented areas
- Micrografting for white/loss of pigmentation
What are some other ways to treat white scars?
Third world countries have neat tricks to help stimulate pigmentation. This applies to areas of vitiligo as well as hypopigmentation from many other causes including infections such as leishmaniasis. Your dermatologist may prescribe some DIY methoxy psoralen creams. Listen to them, I have no experience with this method.
What are future ways to treat hypopigmented scars?
This will be available in the future as mainstream treatment, namely autologous cultured melanocytes. The rules & regulations will differ with your country. Essentially-
- Harvest some pigment cells
- Chuck the in a petri dish
- Give them some food & light
- They have a party & multiply over 2-6 weeks
- Go back & harvest the offspring
- Replant them in white areas.
How much are treatments?
Depending on the severity of your scars, some treatments are covered under Medicare. The medical insurance system in Australia is based upon objectively severe scars, meaning the government only cares on what you look like objective, & not how you feel.
- Micrografting & split grafts- POA, depending on the area.
- Fractional lasers – from $490 (Nurse)
- Microneedling & topicals- from $440
- Phototherapy – no charge. Bulk billed under Medicare
Davin’s Viewpoint on treating hypopigmented scars
In the context of changes of colour, scars can only have one of three variables (it’s not that hard), darker than the surrounding skin (post inflammatory hyperpigmentation), lighter than the surrounding tissue (post inflammatory hypopigmentation) or red, post inflammatory erythema.
Red marks are the easiest to treat- hit hard with a vascular laser. Dark scars are somewhat easier if you have a pico laser (exception is dusky grey dermal dropout). This leaves white scars. They are by far the most difficult to treat as one has to increase the number of active melanocytes or pigment cells. If your cells are asleep, one can wake them up with microneedling, lasers, PGE analogues & topicals.
Inflammation & trauma (scratch, accident, burn) can reduce melanocyte numbers. If this happens, I need to transfer pigment cells from one area to another. This is surgical. There is no other way to reliably replace melanocytes. (Yes, I do know the theory about stem cells, but this is not reliable. I would recommend straight forward cell transfer, compared to transferring a cell that may or maynot give rise to a pigment cell. That may or may not be active!!!)
Hypopigmented scars take time to heal & repigment, especially with lasers, microneedling & topicals. Melanocyte transfer is faster, I often get re-pigmentation within 3-8 weeks of surgery. The scar-recipient site looks somewhat patchy for many months before evening up at 12 months. You are in it for the long haul. Unlike pigment transfer for vitiligo, melanocyte transfer is more stable in scar tissue.
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