Treatment of Acne Scars With Hyaluronic Acid: An Improved Approach

July 2013 | Volume 12 | Issue 7 | Original Article | 121 | Copyright © July 2013

Shlomit Halachmi, MD PhD,a Dan Ben Amitai MD,b,d and Moshe Lapidoth MD MPHc,d

aHerzelia Skin and Laser Center, Herzelia Pituach, Israel bPediatric Dermatology Unit, Schneider Children's Medical Center of Israel, Israel cLaser Unit, Department of Dermatology, Rabin Medical Center, Petach Tikva, Israel dSackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

treated with 20 mg/mL Restylane Vital using the premeasured 10 microliter/dose injector supplied by the manufacturer. The filler was placed in the superficial dermis (Figure 2). Injections were repeated until the defect was visibly corrected.


All the patients with ice pick acne scars of the face underwent Restylane Vital microinjections at the conclusion of a series of fractional resurfacing treatments. All participants tolerated the procedure well, and all were extremely satisfied with the immediate improvement. Adverse events were limited to pinpoint bleeding at the injection site. Figures 3 and 4 show representative results before and immediately after injection.


Acne scarring is a substantial aesthetic problem as it is widely prevalent, affects the face prominently, is poorly masked by cosmetics, and begins at an early age. Despite the advent of aggressive and effective treatments for acne, the problem remains widespread even among young adults. The inflammatory component of acne causes follicular necrosis and periappendageal fibrosis. Since the pilosebaceous unit extends to the deep dermis and subcutaneous fat, the fibrosis frequently extends to the deep tissue, resulting in depressed scars.4 In fact, since the inflammation in inflammatory acne is predominantly beneath the epidermis, dermal scarring and pitting is frequently observed under epidermis that is visually intact after the acne has resolved.5 As the scars mature, they contract, drawing in the surface and forming the characteristic pitting of acne scars. Furthermore, age-related lipoatrophy results in concavities of the cheeks and Lapidothtemples, which reduces the stretch on the scars and exaggerates the appearance of acne scarring as the face matures.
The approach to treating acne scarring is dictated by the type of scar as well as the patient’s skin and expectations. Superficial macular acne scars, which may be erythematous or hyperpigmented, typically improve over 3 to 18 months and do not require treatment.6 At the other end of the spectrum, hypopigmented acne scars are relatively common on the trunk and are very difficult to treat.7 The depressed scars of acne have been classified by Jacob et al into 3 basic categories:6
  1. Ice pick scars: deep and narrow (<2 mm) sharply marginated tracts that extend to the deep dermis or subcutis. Their significant depth makes them inaccessible to conventional skin resurfacing options.
  2. Rolling scars: usually wider (4-5 mm or more). Abnormal fibrous dermal tethering to the subcutis causes a rolling appearance. Since the anchor of the tethers is deep, corrective measures must reach the deep dermis and subcutis.
  3. Boxcar scars: crisp, varicella-like superficial depressions.
This classification was designed to guide the approach to treatment. Ice pick scars have historically been treated by punch excision or punch grafts, as their small size allows for the use of a small punch biopsy.8 Rolling scars, whose deep tethering must be addressed, are well-addressed by subcision, to release the downward vectors.9-11 Boxcar scars, which are more superficial, are well-treated with resurfacing techniques – chemical peels (trichloroacetic acid, glycolic acid, or, less commonly, phenol), dermabrasion, or laser