Acne scars: Classification and treatment

Scarring from acne is one of the most vexing problems in dermatologic surgery. Unlike other areas of cosmetics, it is borne from a medical condition and affects individuals of varying ages. It can negatively affect one’s economic and social opportunities and be devastating to self-esteem. While prevention may be the best cure, access to medical care, compliance, and the increased frequency of adult acne all increase the likelihood of scarring from inflammatory and nodulocystic acne. There are myriad treatments for acne scars. Unfortunately, there is not a “magic” bullet. The Cochrane Review noted in the past that the evidence is rather poor even for laser resurfacing. Part of the difficulty lay in the various topographic shapes and forms in which acne scars come. A practitioner needs to know what he/she is treating in order deliver the proper therapy. There have been several good articles on classification, but still there is not a consensus. With this complicated condition, any text that attempts to bring some order to classification and treatment is most welcome. This book, edited by Tosti, Padova, and Beer, sheds some light on these issues. This book is organized logically into classifying acne scars and the pathophysiology of acne scars followed by a variety of therapeutic modalities. It includes chapters on treating Asian patients and those of African descent. It closes with an overall treatment algorithm. A definite strength of this text is that it combines European and American perspectives on acne scarring. The first chapter reviews the dizzying array of classification schemes. The authors are proponents of using ultrasound in order to more accurately categorize acne scars. Ultimately, they do not offer a single comprehensive classification system. In subsequent chapters, the other authors use a variety of methodologies to classify and treat these scars. The pathophysiology and hypertrophic/keloidal chapter are very perfunctory, perhaps reflecting the lack of a clarifying research in this area. The “meat” of the book focuses on treatment options, and that is really what would interest the working dermatologist. A chapter on topical treatment such as retinoids discusses the prevention of scarring (ie, acne treatment) as much as it does the actual treatment of scars. One senses that topical treatment in already formed scars plays a small role. The next three chapters on traditional resurfacing by chemical peels and dermabrasion are worthy because the authors go into specific details about their techniques and their pre- and postoperative regimens. These techniques will be of value to the reader because they can be applied to other cosmetic conditions. The next chapter on fillers and fat transfer by Flynn and Jones is well written and a good review of the various injectable options. This includes collagen products, which unfortunately will no longer be an option in the United States. Given the international expertise of these two authors on fillers, it would have been helpful if they had gone into more detail about their actual technique, particularly about fat transfer and microdroplet silicone. The needling chapter is a must-read for those interested in collagen induction by the percutaneous roller. This technique is becoming increasingly popular in this country, and for good reason. The results appear promising, although more comparative studies are required. A subsequent chapter by Pirigy and Alam discusses traditional subcision and more invasive techniques, such as excision and punch grafting. This chapter has the best diagrams and schematics of any chapter, which helps clarify the concepts. However, the addition of pre- and postoperative images would have been helpful to define the limitations of these procedures. There are two chapters by Beer and Narurkar on fractional and nonablative and ablative devices. They are well written reviews, but they could have been condensed into one chapter. Despite the development of promising light technologies, they are best used in combination with other modalities for the best outcomes. The biggest advantage that this author has found with fractional devices is that those with high Fitzpatrick skin types can be treated with less risk of postoperative sequelae. Yet it can require many treatments, and the final results may not be evident for several months after the final treatment because of continued collagen remodeling. The chapters on treating patients of color are much needed. They do shed light on the challenges and limitations of treatment, and emphasize not only the need for thorough patient education and expectations, but also the need to develop technology that is “color blind.” In those patients where treatment may not be an option, there is a discussion of corrective cover camouflage. These techniques should not be underestimated in their value, but a section on medical micropigmentation as a permanent solution is also warranted. The book concludes with a chapter on treatment algorithms. While this summary does discuss treatment options for different types of scars, the reader would have benefitted from more diagrams of the actual algorithms for different acne scaring scenarios. Ultimately, the treatment of acne scars requires multiple modalities and patience. This is a worthwhile text to have on the shelf to remind us how challenging this condition is while providing some organization and techniques for managing it.