Combination techniques in the treatment of atrophic acne scars

AUTHOR:

Dr Gabriela Bogucka

specialist in internal medicine, aesthetic medicine doctor

When searching for an effective treatment protocol for difficult atrophic acne scars, it is worth following the principle of “destroy and rebuild” – that is, selecting techniques and technologies that simultaneously break down disorganized collagen fibers within the scar and stimulate its remodeling. As the treatment process is long-term and patients often cannot afford extended downtime, we aim to choose methods that are as minimally invasive as possible, which also translates into improved safety and a reduced risk of complications.

The key to success lies in combining techniques with additive effects within a single treatment session. The following types of acne scars can be distinguished:

• ice pick scars (V-type),
• boxcar scars (M-type),
• rolling scars (U-type),
• superficial (atrophic) scars,
• hypertrophic scars and keloids.

Acne scars represent a significant therapeutic challenge in aesthetic medicine. Their presence is associated with considerable discomfort, loss of self-esteem, and often even depressive symptoms and social withdrawal. When working with patients—especially those with long-standing scars—it is essential to perform an initial assessment of scar types and to explain that the treatment process is long-term and may take several years.

Treatment selection

For acne scar assessment, we use the ECCA quantitative scale and the qualitative Goodman and Baron scale. In everyday clinical practice, for both initial evaluation and monitoring progress, it is also useful to examine the patient under tangential (side) lighting.

Ice pick scars account for approximately 60–70% of atrophic scars. They are narrow but deep, often extending into the subcutaneous tissue, creating a “pulling” effect on the skin. Therefore, mechanical techniques are most effective in their treatment, such as the punching technique (punch excision) and subcision using a cutting cannula. These methods are best combined with TCA CROSS, non-ablative fractional lasers, or microneedle radiofrequency.

Boxcar scars are flat with sharp edges and represent approximately 20–30% of atrophic scars.

Rolling scars are relatively shallow but often confluent and result from chronic inflammation. They create a “wavy” skin appearance and account for about 15–20% of atrophic scars.

In the treatment of boxcar and rolling scars, subcision combined with energy-based treatments—such as ablative and non-ablative lasers or microneedle radiofrequency—is commonly used.

Latest research

Recent clinical studies show a growing advantage of less invasive combination techniques performed in a single session over more aggressive procedures such as ablative lasers. This approach ensures a significantly higher safety profile and improved patient comfort. It also reduces the risk of complications such as hyperpigmentation, hypopigmentation, and prolonged erythema.

It is also worth noting that recent studies suggest that invasive procedures may be safely performed in patients undergoing oral retinoid therapy, creating opportunities for earlier intervention and faster treatment of acne scars.

Over the past two years, very promising clinical data have emerged regarding the use of poly-D,L-lactic acid in acne scar treatment. Seo et al. demonstrated new properties of this compound, showing that beyond stimulating collagen and elastin production, it also reduces oxidative stress and promotes the proliferation of adipose-derived stem cells.

These properties make poly-D,L-lactic acid an excellent adjunct in combination therapies for atrophic acne scars. Promising results have also been demonstrated in studies combining microneedle radiofrequency with the administration of poly-D,L-lactic acid. These studies were conducted using devices already available on the Polish market that allow both procedures to be performed during a single treatment session.

Effects:

Summary

Establishing the most effective treatment for acne scars requires a thorough initial assessment and clear patient education that the process is long-term and may take several years. It is advisable to combine multiple techniques and technologies within a single treatment session, while prioritizing safety and minimizing downtime.

Recent reports indicate the advantage of less invasive combination techniques over treatments using ablative lasers. Hybrid collagen stimulators based on poly-D,L-lactic acid—especially when combined with microneedle radiofrequency—represent a promising addition to therapy, while also improving overall skin quality and tone.

A well-managed patient with atrophic scars, particularly an older patient, can become one of the most satisfied and loyal patients, as in addition to scar reduction, they also gain improved skin quality and overall well-being.

References:

„Acne Scars: An Update on Management” Abdulhadi Jfri, MD, MSc, FRCPC, FAAD; Ali Alajmi, MD, FRCPC, FAAD; Mohammad Alazemi, MD; Malika A. Ladha, MD, FRCPC, FAAD Skin Therapy Letter. 2022;27(6):6-9.

„Safety of performing invasive acne scar treatment and laser hair removal in patients on oral isotretinoin: a retrospective study of 110 patients” Byalakere Shivanna Chandrashekar 1, Danda Venkatesh Varsha, Vani Vasanth, Puttarangappa Jagadish, Chandraiah Madura, Maragowdanahalli Lingegowda Rajashekar 2017 Jul/Aug;21(4):325-333. doi: 10.1177/1203475417701419. Epub 2017 Mar 31.

„Safety of non-ablative fractional laser for acne scars within 1 month after treatment with oral isotretinoin: A randomized split-face controlled trial.” Saluja SS, Walker ML, Summers EM, Tristani-Firouzi P, Smart DR. Lasers Surg Med. 2017 Dec;49(10):886-890. doi: 10.1002/lsm.22711. Epub 2017 Aug 29. Dermatol Surg 2021 Nov 1;47(11):1448-1452. doi: 10.1097/DSS.0000000000003185.

„Treatment of Atrophic Acne Scarring With Fractional Micro-Plasma Radio-Frequency in Chinese Patients: A Prospective Study “ Ting Lan, BS, PhD,1 Yan Xiao, BS,1 Li Tang, BS,1 Michael R. Hamblin, PhD,2,3,4 and Rui Yin, MD, PhD1,* Lasers in Surgery and Medicine 2018 Oct.

„Treatment and Improvement of Healing after Surgical Intervention” Andrea Bueno 1, Endika Nevado-Sanchez 2 3, Rocío Pardo-Hernández 4, Raquel de la Fuente-Anuncibay 4, Jerónimo J Ann Transl Med2021 May;9(10):862. doi: 10.21037/atm-21-1715.

„Comparison of fractionated frequency-doubled 1,064/532 nm picosecond Nd:YAG lasers and non-ablative fractional 1,540 nm Er: glass in the treatment of facial atrophic scars: a randomized, split-face, double-blind trial” Yu Shi 1, Wencai Jiang 2, Wei Li 1, Wei Zhang 1, Ying Zou 1 González-Bernal 4

„Intradermal Injection of Poly-D, L-lactic Acid Using Microneedle Fractional Radiofrequency for Acne Scars” : An Open-Label Prospective trial” Jin Hyeok Hyeong, Joon Woo Jung, Suk Bae Seo, Hong Seok Kim, Kwang Ho Kim.