Advancing the Care of Post-Acne Scarring: Expert Insights Into New Treatment Options

May 2016 | Volume 15 | Issue 5 | Original Article | 518 | Copyright © May 2016

Wm. Philip Werschler MD FAAD FAACS,a Julius W. Few Jr. MD,b Carolyn I. Jacob MD FAAD,c
John H. Joseph MD,d James M. Spencer MD MS,e and Amy Forman Taub MDf

aUniversity of Washington School of Medicine, Seattle, WA; Premier Clinical Research, Spokane, WA
bThe University of Chicago; Northwestern University; The Few Institute for Aesthetic Plastic Surgery, Chicago, IL
cDepartment of Dermatology, Northwestern University Feinberg School of Medicine; Chicago Cosmetic Surgery and Dermatology, Chicago, IL
dDepartment of Head and Neck Surgery, University of California Los Angeles, Los Angeles, CA; Clinical Testing of Beverly Hills, John H. Joseph, MD, Beverly Hills, CA
eSpencer Dermatology and Skin Surgery Center, St. Petersburg, FL
fNorthwestern University Feinberg School of Medicine, Chicago, IL; Advanced Dermatology – Innovative Skincare, Lincolnshire and Glencoe, IL

Most patients with acne have some degree of facial scarring even after their acne resolves, extending the period of psychosocial distress. Unfortunately, management of acne scars remains challenging. Many treatments for post-acne scarring including chemical peels, skin needling, laser resurfacing, surgical repair, subcision lifting, and punch elevation lifting, are limited by moderate and unpredictable results, significant morbidity, and substantial patient investments in time and money. The most recent addition to the armamentarium is tissue augmentation with soft tissue fillers, including a recently approved polymethylmethacrylate-collagen filler. Matching individual patient needs to the appropriate treatment is crucial. While many patients with acne scars have unrealistic expectations about treatment outcomes, open, honest, and realistic dialogue regarding their treatment options and concerns can facilitate realistic expectations. This article is based on a consensus discussion by the authors, who all have experience managing post-acne scarring, as well as the content of a series of live CME-accredited symposia in connection with major dermatology meetings.

J Drugs Dermatol. 2016;15(5):518-525.

The Incidence and Psychosocial Impact of Post-Acne Scarring

Acne vulgaris is a disease of the pilosebaceous unit that affects 40 to 50 million individuals in the United States.1 Approximately 95% to 100% of adolescent boys and 83% to 85% of adolescent girls are affected by acne, which persists into adulthood in up to 20% of cases.2 Postadolescent acne appears to occur more frequently in women than men.3 Although acne is the most frequent primary diagnosis at visits to dermatologists,4 it is often dismissed by patients and physicians alike as a natural part of growing up that has few real consequences.5 However, facial scarring occurs to some degree in 90% to 95% of patients, with both sexes affected equally.6-8 The appearance of atrophic scars can worsen with age, especially if there is concomitant photoaging.9
Post-acne scarring is associated with significant psychosocial distress, comparable to that in patients with active acne lesions.10 Patients with acne scars report low self-esteem, social anxiety, and withdrawal.11 The degree of psychosocial distress is not correlated with the severity, size, or location of the scarring, but rather the patient’s subjective perception of their scars.12,13 A recent study found patient self-assessment of severity—but not clinician assessment—was statistically associated with psychological morbidity such as depression and anxiety.13 Clinicians should consider the psychosocial sequelae of skin disease not only in those with objectively more severe disease, but also in patients across the severity spectrum.13
In the past, post-acne scarring therapies were limited by significant morbidity and marginal improvement.14 While outcomes, safety, and choices have greatly expanded and improved, outcomes remain unpredictable and usually require multiple procedures over time.15 Patient satisfaction with treatments is low; current procedures provide moderate improvement but are generally associated with suboptimal long-term improvements.15-19 Further confounding the process is the lack of consensus regarding efficacy scales or treatment guidelines,18 although a good qualitative scale has been developed.20 Consequently, it is important that clinicians establish realistic expectations with patients prior to treatment selection to facilitate good patient outcomes.

Acne Scar Types and Their Pathophysiology

There appears to be a genetic predisposition to poorly resolving inflammation that underlies post-acne scarring.14 The degree.