Acne scars have historically been problematic for both patients and the doctors who wish to help them. We are proud to say that patients who seek Dr. Rapaport’s guidance at the Cosmetic Skin and Surgery Center have access to the most effective methods currently available to treat scars.
Acne Vulgaris: Acne Vulgaris is the most common form of acne. Hormones and other etiology are the cause. The response for most people diminishes over time and acne thus tends to disappear, or at least decrease, after one reaches their early twenties. There is, however, no way to predict how long it will take for it to disappear entirely, and some individuals will continue to suffer from acne decades later, into their thirties and forties and even beyond. It includes several types of pimples. These acne lesions include blackheads, whiteheads, papules, pustules, nodules and cysts.
Mild to Moderate acne vulgaris consists of the following types of acne spots:
Whiteheads: Whiteheads are formed when a pore is completely blocked, trapping sebum (oil), bacteria, and dead skin cells, causing a white appearance on the surface. In other words, Whiteheads are a combination of oils, sebum and cellular fragments that produce firm to hard plugs within hair follicles. They are closed from the skin’s surface by cellular debris at the follicle opening. Because they have no contact with oxygen, they do not oxidize or turn brown, as blackheads do. They form a light or yellow-white lump and are called milia (or milium, singular). When bacteria is added to these plugs, the condition can lead to acne, especially cystic acne.Whiteheads are promoted by excessive cellular exfoliation, which quickly clog or block the follicles. Some skin specialists believe individuals with frequent and multiple blackheads and whiteheads produce sebum that is drier than normal and conducive to forming firm plugs. Whiteheads are normally quicker in life cycle than blackheads
Blackheads: These appear when a pore is only partially blocked, allowing some of the trapped sebum (oil), bacteria, and dead skin cells to slowly drain to the surface. The black color of a black head is caused by reaction of the skin’s own pigment, melanin, reacting with the oxygen in the air. A blackhead is much more stable than a white head and takes a long time to clear. When bacteria is added to black heads, the condition can lead to acne
Papules: Dermatologists call any small solid circumscribed bump in the skin a papule, as opposed to a vesicle which contains fluid or a macule which is flat and even with the surrounding skin. Papules are normally inflamed, pink or red in color. Squeezing a papule is not recommended as it might lead to scarring
Severe acne vulgaris results in:
Nodules: As opposed to the lesions mentioned above, nodular acne consists of acne spots which are much larger, can be quite painful and can sometimes last for months. Nodules are large, hard bumps under the skin’s surface. Scarring is common. Absolutely do not attempt to squeeze such a lesion. You may cause severe trauma to the skin and the lesion may last for months longer than it normally would. Dermatologists often have ways of lessening swelling and preventing scarring.
Cysts: An acne cyst can appear similar to a nodule, but is pus-filled, and has been described as having a diameter of 5mm or more across. They can be painful. Again, scarring is common with cystic acne. Squeezing an acne cyst may cause a deeper infection and more painful inflammation which will last much longer than if you had left it alone. Dermatologists often have ways of lessening swelling and preventing scarring.
Acne Rosacea: Acne Rosacea can look similar to the aforementioned acne vulgaris, and the two types of acne are sometimes confused for one another.
Rosacea affects millions of people, generally females above the age of 30. It affects the middle third of the face, and symptoms include skin redness and swelling in the areas that typically flush when we’re excited or embarrassed; telangiectases (the appearance of broken blood vessels), and, occasionally, acne-like papules and pustules. For this reason, rosacea is often misdiagnosed as acne and treated with acne medications. Without appropriate medical treatment Rosacea can cause swelling of the nose and excessive tissue growth resulting in a condition known as Rhinophyma.
Rosacea tends to be more frequent in women but more severe in men. If you think you may have rosacea, see a dermatologist right away. While there is no known cure for this condition, it is treatable – and early treatment will help prevent permanent damage to your skin.
Acne Mechanica: Acne Mechanica is the acne that develops when skin is under pressure, is undergoing friction, is covered tightly or is exposed to heat.
Some situations when Acne Mechanica may form are:
Some examples of such pressure that may cause acne mechanica are:
Any situation during which the skin is tightly covered with cloth, rubbed and pressurized makes it vulnerable to acne mechanica. For example, people who wear very tight clothes made of synthetic material may get acne mechanica.
Who are more prone to acne mechanica?
The treatment of acne mechanica is similar to that of Acne vulgaris.
To Avoid Acne Mechanica:
Severe Forms of Acne are rare, but they are a great hardship to the people who experience them, and can be disfiguring and, like all forms of acne, can have psychological effects on the sufferer.
Severe forms of acne comprise of:
Acne Conglobata: This is the most severe form of acne vulgaris and is more common in males. It is characterized by numerous large lesions, which are sometimes interconnected, along with widespread blackheads. It can cause severe, irrevocable damage to the skin, and disfiguring scarring. It is found on the face, chest, back, buttocks, upper arms, and thighs. The age of onset for acne conglobata is usually between 18 and 30 years, and the condition can stay active for many years. As with all forms of acne, the cause of acne conglobata is unknown. Treatment usually includes isotretinoin (Accutane), and although acne conglobata is sometimes resistant to treatment, it can often be controlled through aggressive treatment over time.
Acne Fulminans: This is an abrupt onset of acne conglobata which normally afflicts young men. Symptoms of severe nodulocystic, often ulcerating acne are apparent. As with acne conglobata, extreme, disfiguring scarring is common. Acne fulminans is unique in that it also includes a fever and aching of the joints. Acne fulminans does not respond well to antibiotics. Isotretinoin (Accutane) and oral steroids are normally prescribed.
Gram-Negative Folliculitis: This condition is a bacterial infection characterized by pustules and cysts, possibly occurring as a complication resulting from a long term antibiotic treatment of acne vulgaris. It is a rare condition, and we do not know if it is more common in males or females at this time. Fortunately, isotretinoin (Accutane) is often effective in combating gram-negative folliculitis.
Pyoderma Faciale: This type of severe facial acne affects only females, usually between the ages of 20 to 40 years old, and is characterized by painful large nodules, pustules and sores which may leave scarring. It begins abruptly, and may occur on the skin of a woman who has never had acne before. It is confined to the face, and usually does not last longer than one year, but can wreak havoc in a very short time.
BACKGROUND: Acne scarring is a common complication of acne and yet no appropriate and effective single treatment modality has been developed. We suggest a technique consisting of the focal application of higher trichloroacetic acid (TCA) concentrations by pressing hard on the entire depressed area of atrophic acne scars. This technique is called chemical reconstruction of skin scars (CROSS) by the authors.
OBJECTIVE: To evaluate the clinical effects of CROSS on atrophic acne scars in dark-complexioned patients.
METHODS: An analysis was conducted of 65 patients with atrophic acne scars who were treated with CROSS in our hospitals between July 1996 and July 2001. Thirty-three patients were treated with 65% TCA CROSS and 32 patients were treated with 100% TCA CROSS. All patients had Fitzpatrick skin types N-V.
RESULTS: Patient treatment data indicated that 27 of 33 patients (82%) (the 65% TCA group) and 30 of 32 patients (94%) (the 100% TCA group) experienced a good clinical response. All patients in the 100% TCA group who received five or six courses of treatment showed excellent results. Good satisfaction rates in the 65% and 100% TCA groups were re_ corded. There were no cases of significant complication.
CONCLUSION: CROSS is a safe and very effective single modality for the treatment of atrophic acne scars with no significant complications.
J. B. LEE, MD, W. G. CHUNG, MD, H. KWAHCK, MD, AND K. H. LEE, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.
TRICHLOROACETIC ACID (TCA) has a particularly long history as an effective agent for rendering histologic and clinical improvement to the skin and is particularly safe when used as a superficial peel or in “combination peels” of medium depth for acne scars. Application of TCA to the skin causes precipitation of proteins and coagulative necrosis of cells in the epidermis and necrosis of collagen in the papillary to upper reticular dermis. Over several days the necrotic layers slough and the skin reepithelializes from the adnexal structures that were spared from chemical damage. Dermal collagen remodeling after chemical peel may continue for several months. Many investigators have observed that the clinical effects of TCA were due to both reorganization in dermal structural elements and an increase in dermal volume as a result of an increase in collagen content, glycosaminoglycan, and elastin.
Recent studies have shown that the reticular dermis heals with scarring. They offer an explanation for some of the increased risk associated with the use of TCA for deeper peels, suggesting that peeling with higher TCA concentrations is very risky and definitely not recommended. We also have limited experience and very little information regarding the effects of higher TCA concentrations for acne scars in dark
complexioned patients, including Koreans (types IV
VI), whose skin is known to develop postinflammatory hyperpigmentation.
In order to maximize the effects of TCA and to overcome complications such as scarring, hyperpigmentation, and hypopigmentation, we suggest a technique consisting of the focal application of higher TCA concentrations by pressing hard on the entire de
pressed area of atrophic acne scars using a sharpened wooden applicator. Eventually it produces multiple, frosted white spots on each acne scar. This technique is called chemical reconstruction of skin scars (CROSS) by the authors; however, the technique itself has not been patented or restricted to prevent usage. The CROSS method, achieved with 65% or 100% TCA alone, has the advantage of reconstructing acne scars by focusing on the dermal thickening and collagen production that increase with high TCA concentrations. Healing is more rapid and has a lower complication rate than conventional full-face medium to deep chemical resurfacing, because the adjacent normal tissue and adnexal structures are spared. This technique does not involve the classic full-face chemical resurfacing, but rather it can be used on focal chemical scar reconstruction. We have used this technique successfully for treating facial acne scars and dilated pores for the past 10 years. The purpose of this study was to evaluate the clinical effects of the CROSS method on atrophic acne scars in dark-complexioned patients.
Materials and Methods:
An analysis was conducted of 65 patients with atrophic acne scars who were treated with the CROSS method in our hospitals between July 1996 and July 2001. The CROSS method consists of the focal application of higher TCA concentrations by pressing hard on the entire depressed area of atrophic acne scars using a sharpened wooden applicator. TCA, 65-100% weight/volume, unbuffered, was made to order by a local pharmacy.
The patients’ ages ranged from 25 to 45 years (mean 32.5 years). Fifty-five patients were women and 10 were men. All patients had Fitzpatrick skin types IV-V. Thirty
three patients were treated with 65% TCA CROSS and 32 with 100% TCA CROSS.
For independent clinical assessment, two blinded physicians evaluated the photographs taken before treatment and 6 months after completion of the treatment. Physicians categorized the improvement as follows: excellent, improvement greater than 70%; good, improvement of 50-70%; fair, improvement of 30-50%; poor, improvement less than 30%. The patient satisfaction rates were recorded from the inter
views conducted 6 months after the last treatment. The physicians evaluated complications such as persistent erythema, permanent hyperpigmentation, hypopigmentation, herpes simplex flare-up, scarring, or keloids.
Patients were evaluated carefully before treatment about the factors considered important, including the patients’ current and past medications and active acne lesion. Rele
vant history was obtained, including any history of prior hy
pertrophic scarring, keloids, allergies, or herpes simplex in
fection. Before CROSS, pretreatments such as tretinoin cream were not applied because of the risk of unpredictable and excessive TCA penetration.
Local anesthetics or sedation were not needed for CROSS. Patients were comfortable during the procedure. After facial washing with soap, the skin was cleansed with alcohol. And then either 65% TCA or 100% TCA was focally applied by pressing hard on the entire depressed area of atrophic acne scars using a sharpened wooden applicator. The skin was monitored carefully until it reached a “frosted” appearance after a single application. The frosted appearance is the result of coagulation of epidermal and dermal proteins and is used mainly to monitor the peel depth. Focal application of TCA produced even frosted spots on each acne scar within 10 seconds. After CROSS, an ointment
based antibiotic instead of an occlusive dressing was applied for moisturizing effect, but this application was discontinued after crust formation in order to avoid the risk of detaching the crust. Oral prophylaxis consisting of antibiotics and anti
viral medications were not needed after CROSS. One to 2 weeks after CROSS, a moisturizer sunscreen cream consisting of 0.05% tretinoin, 5% hydroquinone, and a hydro base was used in some patients for a minimum of 4 weeks. The application of makeup was allowed after CROSS. CROSS was repeatedly performed every 1-3 months to allow dermal thickening and collagen production.
The patient treatment data indicated that 27 of 33 patients (82%) (the 65% TCA group) and 30 of 32 patients (94%) (the 100% TCA group) experienced a good clinical response (Table 1). In the 65% TCA group, 15 of 15 patients (100%) who received more than six courses of treatment demonstrated good or excellent results, as did 2 of 5 patients (40%) who received treatment three times (Table 1 and Figure 3). Of interest is that all patients in the 100% TCA group who received five or six courses of treatment showed excellent results (Table 1 and Figure 4). Table 1 shows that the clinical effects of 100% TCA CROSS were better than those of 65% TCA CROSS.
Good satisfaction rates in the 65% and 100% TCA groups were recorded in 27 of 33 patients (82%) and 30 of 32 patients (94%), respectively (Table 2). In the 65% TCA group, 16 of 33 patients (49%) and 11 of 33 patients (33 %) were satisfied with this therapy absolutely and moderately, respectively (Table 2). In the 100% TCA group, 19 of 32 patients (59%) and 11 of 34 patients (34%) were satisfied absolutely and moderately, respectively (Table 2).
There were no cases of significant complication at the treatment sites such as persistent erythema, permanent hyperpigmentation, hypopigmentation, herpes simplex flare-up, scarring, or keloids. Relative to the 65% TCA CROSS treatment, 100% TCA CROSS did not increase the frequency of complications. Only mild erythema, which faded over 2-8 weeks, and transient postinflammatory hyperpigmentation, which dis
appeared over 6 weeks, occurred. Mild pustular eruptions occurred in only four patients and cleared within 1 week with the use of cefadroxil 500 mg three times a day. The two patients who received isotretinoin for 3 months before treatment showed good results without excessive scarring, although it should be noted that full-face medium to deep chemical resurfacing is rela
tively contraindicated in patients who have taken isotretinoin within the previous 6 months because of the increased risk of hypertrophic scarring.
The results indicated that higher treatment frequency of CROSS application on acne scars improved the therapeutic effect, and there were no significant complications. Furthermore, application of a higher TCA concentration was more effective in the treatment of atrophic acne scars.
Acne is a chronic inflammatory disease of the pilosebaceous unit and a condition commonly experienced in adolescents, but recent data indicate that the prevalence of clinical acne does not show a significant decrease in women between the ages of 25 and 44 years.12 Acne scars are more common in this persistent acne group, because acne scars correlate with the duration of acne. Minor acne scarring may occur in up to 95% of patients, but to a significant degree in only 22 %.
Recently acne scars have been classified into three types: icepick, rolling, and boxcar. Various treatment modalities are used for reconstructing and improving the appearance of acne scars, including punch excision, punch elevation, subcutaneous incision (subcision), chemical skin resurfacing, and laser skin resurfacing. By combining these multiple modalities, it is possible to produce dramatic improvement in acne scars. However, procedures that include chemical skin resurfacing have generally been limited to skin types N-VJ. So far, no appropriate and effective single treatment modality has been developed for reconstructing and ameliorating the appearance of acne scars.
Most surgeons want to use higher TCA concentrations because they produce increased dermal thickening and collagen volume. However, such use results in resurfacing difficulties and can produce severe scarring because of damage to the adjacent normal skin, although severe scarring usually does not occur in re
surfacing with lower TCA concentrations because of reepithelialization from hair follicles and adjacent normal tissue that were spared from chemical damage. So peeling with higher TCA concentrations is very risky and definitely not recommended.
We suggest the CROSS method, which consists of the focal application of higher TCA concentrations, even up to 100%, by pressing hard on the entire depressed area of atrophic acne scars using a sharpened wooden applicator. This technique, achieved with higher TCA concentrations of 65% or 100% TCA alone, has the great advantage of reconstructing the acne scars by focusing on the dermal thickening and collagen production that increases with high TCA concentrations. Of interest is that rather than being equivalent to the classic full-face chemical resurfacing, this technique can be used on focal chemical scar reconstruction. Moreover, this technique can avoid scarring and reduce the risk of developing hypopigmentation by sparing the adjacent normal skin and adnexal structures. We found that in using the CROSS method, application with 100% TCA was more effective in treating atrophic acne scars than with 65% TCA.
Repeated CROSS application can normalize deep rolling and boxcar scars, and a similar result can be achieved for deep icepick scars with higher TCA concentrations of up to 100%. Because clinical improvement is proportional to the number of courses of CROSS treatment, this method is effective for the treatment of all deep acne scar types. Furthermore, it can also be utilized for autologous soft tissue augmentation prior to performing the classic fullface resurfacing modalities for deeply pitted areas.20 Also, we have used this technique successfully for treating dilated pores. Recently we used the CROSS method for reconstructing depressed surgical scars.
No patient developed any significant complication such as persistent erythema, permanent hyperpigmentation, hypopigmentation, scarring, or keloids. The use of 100% TCA CROSS did not increase the frequency of complications compared with 65% TCA CROSS. All cases of mild erythema and transient postinflammatory hyperpigmentation faded over 1-2 months and focal skin infections were cleared by oral antibiotics. No herpes simplex flareup occurred in the nine patients with a positive history of herpes without oral antiviral prophylaxis.
A history of drugs that depress adnexal glands, such as isotretinoin, is a relative contraindication tomedium to deep chemical resurfacing because of the increased risk of developing hypertrophic scars.3 We believe that a drug history of isotretinoin is not a relative contraindication and does not influence the clinical results because CROSS may spare the adjacent normal skin. But further study is required to determine the effect of isotretinoin in CROSS.
We conclude that the CROSS method presented in this study is a safe and very effective single modality for the treatment of atrophic acne scars with no significant complications. The degree of clinical improvement was proportional to the number of courses of CROSS treatment, with good improvement after three to six courses being recorded in more than 90% of cases. Most patients, 82% in the 65% TCA group and 94% in the 100% TCA group, were satisfied with the CROSS method. Furthermore, the CROSS method with 100% TCA was more effective in treating atrophic acne scars than with 65% TCA.
This is a novel technique not yet reponed in North America. The simplicity of this procedure makes this an easier procedure for the clinician and more patient friendly than more conventional dermabrasion or CO2 laser resurfacing. It also requires less equipment than nonablative laser treatments of scars. I hope that others will now try this technique so that more experience can be reponed in our literature.
We offer state-of-the-art skin cancer removal procedure called “Mohs Micrographic Surgery” at The Cosmetic Skin and Surgery Center by our Mohs Surgeon, Dr. Matthew B. Quan. The procedure was invented in the 1930′s by Fredrick Mohs, M.D., at The University of Wisconsin to remove complicated skin cancers unresponsive to traditional therapies. To be a Mohs Surgeon in the American College of Mohs Micrographic Surgery and Cutaneous Oncology a special fellowship is required. In addition to the Mohs Surgeon, who serves as the Surgeon and the Pathologist, a certified histotechnologist is employed to process the tissue specimen.
You may have been referred for Mohs Surgery in our surgical suite because your skin cancer requires special treatment.
Several effective methods are available for the treatment of skin cancer. The treatment choice is dependent on several factors including size, previous treatment, location, and tumor type. Mohs Surgery is indicated for basal and squamous cell skin cancers and provides the highest cure rate for both primary (first time) cancers and recurrent (previously treated but then came back) cancers. Mohs Surgery is a complex procedure combining surgical excision with immediate microscopic examination of the entire tissue specimen margin by frozen tissue processing techniques right in the office. It consists of five steps:
The Mohs Surgery technique allows us to examine 100% of the surgical margin and, if tumor is still present, pinpoint the precise location of the leftover cancer. This allows us to selectively remove another layer of skin from the area only where the cancer remains. This minimizes the normal skin that is removed. Since some skin cancers removed with Mohs Surgery are complicated, multiple stages may be necessary. Examination of each stage takes up to 60 minutes. If multiple stages are taken, the Mohs procedure can take up a good part of the day, so you must reserve the entire day for this surgery.
How To Prepare For Your Surgery
Please be prepared to have a scar! Unfortunately, skin cancers are often larger than seen by the naked eye and, as a result, the scars are frequently much larger than expected. Our primary goal is to remove all the cancer the day you come in. After it is totally removed, every effort will be made to leave you with as excellent a cosmetic result as possible.
What To Expect The Day Of Surgery
If the cancer is on the face, it is advisable to keep your head elevated while sleeping or resting with an extra pillow or two for one or two weeks after the surgery. This reduces swelling. Sometimes, if the cancer is anywhere remotely near the eye, you may get one or two “black eyes” after the procedure; the worst day being about three days later. No treatment is necessary. Although cold compresses may be helpful. Although in most cases the wound looks well after the stitches are removed, often it may take weeks to months of careful wound care to the scar site. Therefore, we ask that you be certain not to plan any important social events or out-of-town trips for several weeks following the surgery.