While there are a number of techniques available to reduce the unsightliness of a scar, using lasers to treat scars caused by acne is a tried-and-true approach, often with excellent results. But with so many different lasers on the market- it can be hard to figure out where to start. The most important factor in deciding which approach will work best for you is figuring out what kind of scars you are dealing with. Not all scars are created equally, meaning treatments will vary. Depending on the type and depth of the scar you are trying to treat- different lasers may work better than others. Let’s start with a review of scar types.
When it comes to acne scars, different types of acne can leave behind different scar formations. This is because the individual lesion in question may originate from varied locations in the skin or because each person’s body heals differently. There are many variables when it comes to acne and its resulting scars. Cystic acne, for example, can cause deeper scars in their wake. Conversely, more superficial acne might result in shallower scars. As a rule of thumb, picking or squeezing pustules is discouraged since it can traumatize the skin more than if the lesions are left to resolve on their own.
Of course, not all scars result from acne, but for this discussion, we focus on facial scars resulting from acne. Acne can cause atrophic, hypertrophic, or keloid scars, with atrophic scars being the most common.
Boxcar scars typically form from chronic inflammatory acne. They have a square shape with rough edges and are usually shallow. Often there are quite a few of these scars, but for some, the scars are more scattered and fewer in number. Boxcar scars tend to measure a few millimeters across and can be treated effectively with a laser.
Icepick scars have a smaller diameter than boxcar scars and are usually deeper. They have a wider opening at the top of the skin’s surface and become narrower at the base of the scar. These scars sometimes form in the wake of comedonal acne, and there might be lots, or just a couple, depending on severity. This type of scarring is notoriously difficult to treat, mostly due to its depth.
Rolling scars are a broader type of atrophic scar around 5mm in diameter and usually cover a more significant portion of the skin. They may be all over the face due to deep, widespread, and sometimes cystic acne. Rolling scars result when bands of scar tissue form, creating tethers that pull the epidermis down. This creates their undulating appearance; rolling scars might need additional therapies beyond lasers, such as subcision, to fully release the scar tethers.
Ablative lasers work by removing layers of the skin such that they can regenerate new, healthy tissue that replaces the scars. Non-ablative lasers work differently and do not remove layers or skin cells. Another way to categorize lasers is if they are resurfacing vs. fractional. Fractional lasers create microchannels using thermal energy, and when these channels heal, the skin becomes tighter and smoother, and collagen is restored. Choosing one technology over another may come down to cost, downtime, the need for repeat treatments, and your consultation with Dr. Boger.
One of the most effective ablative lasers is fractional CO2, a tried-and-true approach for treating acne scars. This aggressive but highly effective laser can be fine-tuned to treat boxcar scars by creating controlled damage to the skin using microscopic holes. CO2 resurfacing lasers require downtime, meaning you might have to stay home and avoid the sun, and your skin will likely take a week or longer to heal. You may have scabs and redness following CO2 laser treatment. Patients with ice pick and rolling scars often benefit from a fractional CO2 laser; however, they may also resolve with a laser that targets the dermis.
A pico (or fractional picosecond) laser is a non-ablative laser that can improve ice pick and rolling scars using a different mechanism of action than an ablative laser. Pico lasers create ultra-short pulses of energy that penetrate the dermis, causing the skin to produce collagen in response. These lasers will have less downtime and fewer risks, including less pain and swelling, but might also require additional treatments to be effective.
Nd:YAG and the newer Er:YAG lasers can be great for resurfacing and are gentler than CO2. Modern lasers have become more effective by using short energy pulses around the scar’s borders and longer pulses to target deeper depressions. New YAG lasers can be customized for the individual scar being treated. YAG lasers can even be used to treat rolling scars, though additional therapies may be needed because rolling scars are tethered to the dermis. With less pain and downtime, this laser is also one of the more expensive options.
Besides downtime, the costs of treatments can be a major factor in making a choice. In general, ablative lasers are more expensive than non-ablative options, but we work with you to develop a comprehensive plan. Remember, sometimes the less expensive treatments require more sessions, meaning you could be better off choosing the more expensive option that requires fewer treatments. Research has shown that more aggressive and ablative lasers are more effective for treating acne scars than gentle non-ablative options. If you have significant acne scars and are willing to take a few days off- an ablative fractional laser is likely the best option.