Acne ScarsI recently finished pouring through the last 2 years of acne scar research and have updated the scars page. It’s an evolving field. Here’s what I found:

Lasers are becoming more and more the go-to treatment for acne scarring. Fractional lasers, which treat only a fraction of the skin at once, are also becoming more popular for their ability to reduce side effects while still producing results.

Scientists are incorporating radiofrequency devices along with lasers and data is promising, while not earthshattering, that radiofrequency could help a bit.

Scar revision specialists have treated scars with fat injections for years with lots of success. However, recently, they are trying what they call autologous fibroblasts, which are cultured connective tissue cells from the person’s own body. This is also showing lots of promise.

Despite the advances, a person embarking on scar revision should not expect miracles, but should instead expect improvement. As always, data is showing that a combination of treatments (i.e. laser combined with subcision and augmentation) produces the best outcomes especially in more severe scarring. According to an article in the journal Dermatologic Surgery, “Severe grades of scarring often require a combination of filling agents for volume deficit, injectable agents for hypertrophic disease, neurotoxins to effect movement, and fractionated and ablative resurfacing for surface changes.”

Lastly, there appears to be vast confusion amongst dermatologists in the classification of acne scars. This highlights the need to carefully select a scar revision expert who is dedicated to and experienced in this specific area of surgery. If you decide to embark upon acne scar revision, do your homework and make sure you go with someone who specializes in acne scars.

Helpful links:
Acne.org Scar Forum: join in the discussion
Acne.org Scar Gallery: share your pictures

References:

  • Leheta TM, Abdel Hay RM, El Garem YF. “Deep peeling using phenol versus percutaneous collagen induction combined with trichloroacetic acid 20% in atrophic post-acne scars; a randomized controlled trial.” The Journal of Dermatologic Treatment. 2014; 25(2): 130-6.
  • Nirmal B, et al. “Efficacy and safety of Erbium-doped Yttrium Aluminium Garnet fractional resurfacing laser for treatment of facial acne scars.” Indian Journal of Dermatology. 2013; 79(2): 193-8.
  • Al-Dhalimi MA, Arnoos AA. “Subcision for treatment of rolling acne scars in Iraqi patients: a clinical study.” Journal of Cosmetic Dermatology. 2012; 11(2): 144-50.
  • Manuskiatti W, et al. “Comparison of fractional erbium-doped yttrium aluminum garnet and carbon dioxide lasers in resurfacing of atrophic acne scars in Asians.” Dermatologic Surgery. 2013; 39(1 Pt 1): 111-20.
  • Sardana K, et al. “Histological validity and clinical evidence for use of fractional lasers for acne scars.” Journal of Cutaneous and Aesthetic Surgery. 2012; 5(2): 75-90.
  • Bencini PL, et al. “Nonablative fractional photothermolysis for acne scars: clinical and in vivo microscopic documentation of treatment efficacy.” Dermatologic Therapy. 2012; 25(5): 463-7.
  • Maluki AH, Mohammad FH. “Treatment of atrophic facial scars of acne vulgaris by Q-Switched Nd:YAG (Neodymium: Yttrium-Aluminum-Garnet) laser 1064 nm wavelength.” Journal of Cosmetic and Laser Therapy. 2012; 14(5): 224-33.
  • Hedelund L, et al. “Fractional CO2 laser resurfacing for atrophic acne scars: a randomized controlled trial with blinded response evaluation.” Lasers in Surgery and Medicine. 2012; 44(6): 447-52.
  • Qian H, et al. “Treatment of acne scarring with fractional CO2 laser.” Journal of Cosmetic and Laser Therapy. 2012; 14(4): 162-5.
  • Huang L. “A new modality for fractional CO2 laser resurfacing for acne scars in Asians.” Lasers in Medical Science. 2013; 28(2): 627-32.
  • Kimura U, et al. “Biophysical evaluation of fractional laser skin resurfacing with an Er: YSGG laser device in Japanese skin.” The Journal of Drugs in Dermatology. 2012; 11(5): 637-42.
  • Cho SI, et al. “Evaluation of the clnical efficacy of fractional radiofrequency microneedle treatment in acne scars and large facial pores.” Dermatologic Surgery. 2012; 38(7 Pt 1): 1017-24.
  • Ong MW, Bashir SJ. “Fractional laser resurfacing for acne scars: a review.” British Journal of Dermatology. 2012; 166(6): 1160-9.
  • Wada T, et al. “Efficacy and safety of a low-energy double-pass 1450-nm diode laser for the treatment of acne scars.” Photomedicine and Laser Surgery. 2012: 30(2): 107-11.
  • Azzam OA, et al. “Fractional CO(2) laser treatment vs autologous fat transfer in the treatment of acne scars: a comparative study.” The Journal of Drugs in Dermatology. 2013; 12(1): e7-e13.
  • Lorenc ZP. “Techniques for the optimization of facial and non-facial volumization with injectable poly-l-lactic acid.” Aesthetic Plastic Surgery. 2012; 36(5): 1222-9.
  • Halachmi S, Amitai DB, Lapidoth M. “Treatment of acne scars with hyaluronic Acid: an improved approach.” The Journal of Drugs in Dermatology. 2013; 12(7): 3121-3.
  • Goodman GJ. “Treating scars: addressing surface, volume, and movement to expedite optimal results. Part 2: more-severe grades of scarring.” Dermatologic Surgery. 2012; 38(8): 1310-21.
  • Tenna S, et al. “Combined use of fractional CO2 laser and radiofrequency waves to treat acne scars: a pilot study on 15 patients.” Journal of Cosmetic and Laser Therapy. 2012; 14(4): 166-71.
  • Zhang Z, et al. “Comparison of a fractional microplasma radio frequency technology and carbon dioxide fractional laser for the treatment of atrophic acne scars: a randomized split-face clinical study.” Dermatologic Surgery. 2013; 39(4): 559-66.
  • Leheta TM, et al. “Do combined alternating sessions of 1540 nm nonablative fractional laser and percutaneous collagen induction with trichloroacetic acid 20% show better results than each individual modality in the treatment of atrophic acne scars? A randomized controlled trial.” The Journal of Dermatologic Treatment. 2014; 25(2): 137-41.
  • Lee SJ, et al. “Ablative non-fractional lasers for atrophic facial acne scars: a new modality of erbium:YAG laser resurfacing in Asians.” Lasers in Medical Science. 2014; 29(2): 615-9.
  • Shah S, Alam M. “Laser resurfacing pearls.” Seminars in Plastic Surgery. 2012; 26(3): 131-6.
  • Preissig J, Hamilton K, Markus R. “Current Laser Resurfacing Technologies: A Review that Delves Beneath the Surface.” Seminars in Plastic Surgery. 2012; 26(3): 109-16.
  • Mohammed G. “Randomized clinical trial of CO2 laser pinpoint irradiation technique with/without needling for ice pick acne scars.” Journal of Cosmetic and Laser Therapy. 2013; 15(3): 177-82.
  • Finlay AT, et al. “Classification of acne scars is difficult even for acne experts.” Journal of the European Academy of Dermatology and Venereology. 2013; 27(3): 391-93.
  • Kwok T, Rao J. “Laser management of acne scarring.” Skin Therapy Letter. 2012; 17(2): 4-6.
  • Sobanko JF, Alster TS. “Management of acne scarring, part I: a comparative review of laser surgical approaches.” American Journal of Clinical Dermatology. 2012; 13(5): 319-30.
  • Levy LL, Zeichner JA. “Management of acne scarring, part II: a comparative review of non-laser-based, nominally invasive approaches.” American Journal of Clinical Dermatology. 2012; 13(5): 331-40.
  • Munavalli GS, et al. “Successful treatment of depressed, distensible acne scars using autologous fibroblasts: a multi-site, prospective, double blind, placebo-controlled clinical trial.” Dermatologic Surgery. 2013; 39(8): 1226-36.

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You guys have been asking, so here’s what I found to be the most interesting new information on scars and scar treatments:


Subcision plus suction.  Subcision is where a needle is placed sideways underneath a depressed scar and moved around, thereby disconnecting the scar from the skin below and allowing it to float up to the surface. The hope is that a hemorrhage will appear under the scar, leading to new connective tissue and a permanent raising of the scar toward the skin surface. For those of you who have tried this, you may have noticed that it seems to work, but that a large portion of these areas tend to recede again. However, a new common sense treatment is now being added to some subcision treatments. After the initial subcision of the scar an initial hemorrhage forms. Then, 3 days later, a suction machine, normally the same one used in microdermabrasion, is placed over the scar area and “vacuums” the skin up, ultimately reintroducing another hemorrhage under the treatment area.  This suctioning is repeated at least every other day for 2 weeks afterward in an attempt to produce more tissue under the scar. The Journal of the European Academy of Dermatology and Venereology concluded, “Frequent suctioning at the recurrence period of subcision increases subcision efficacy remarkably and causes significant and persistent improvement in short time, without considerable complication, in depressed scars of the face.” Pretty cool.


Need to wait until 6-12 months after Accutane (isotretinoin) to get aggressive scar treatment? This is a commonly held belief since isotretinoin has been linked to keloids and raised scarring, perhaps because of collagen accumulation. It remains a prudent stance. However, in one very small study, doctors dermabraded one square centimeter on 7 participants faces using a diamond fraise while they were on isotretinoin. After 6 months, the scar revision appeared successful and there were no signs of keloid or raised scarring. Although this is interesting, patients and doctors must continue to proceed with caution in this area until we get more evidence.


Why do we scar in the first place? Scars are the result of wound healing, which is one of the most complex biological processes, and includes the following 3 phases.  Some new info below:

(1) Inflammation: Upon closer investigation through biopsy specimens, researchers found that the initial inflammatory reaction was stronger and had a longer duration in patients who scarred.

(2) Granulation tissue formation:  Next, damaged tissues are repaired, new capillaries are formed, and new collagen begins forming. Researchers are noting, “The balance of collagen types shifts in mature scars to be similar to that of ounwounded skin, with approximately 80% of type I collagen.”  This one is a bit above my head. If anyone knows why this might be interesting, please comment.

(3) Matrix remodeling: As the healing process moves on, extracellular matrix metalloproteinases (MMPs) take on the job of deciding how much tissue will be built.  Too much MMPs and you may see a raised scar.  Too little and you may see a depressed scar.  However, why some people have too much or too little MMPs remains a mystery.


I’ve read all the other scar related research that has been published as well. Basically it’s mostly the same stuff we have known before. The bulk of the evidence continues to show (1) significant improvement with ablative lasers (CO2 and Erbium;YAG) with pretty severe down time afterward, (2) somewhat less improvement with fractional lasers and needling but with less down time, and (3) the never-ending search for the perfect filler. If anything remarkable comes out in the near future I will let you know.


What it is:  On June 21, 2011 the FDA approved a process by which a dermatologist or plastic surgeon numbs behind the ear, removes small pieces of skin, and sends these pieces of skin to a lab where the fibroblast cells in the skin samples are multiplied many times over and then frozen. These cells are then thawed when needed and injected into the skin under wrinkles or scars (boxcar or rolling) to help even out the appearance of the skin.

PROS: The body views these cultured cells as “own” and so the immune system does not respond. Working with your own cells eliminates allergic reactions, lumps, or abscesses which may come with other fillers. But probably the most compelling advantage is how long results last. Other fillers like bovine or synthetic collagen may last only a few months, and even more advanced fillers which combine polymer beads with collagen may only last a year or so. The LaViv treatment promises to last for years. As with many fillers, recovery is extremely minor and is evidenced by minor redness or bruising at the injection site. You can immediately return to work.

CONS: People don’t see results right away. The process requires 3 staggered injections and results aren’t seen until up to 3 months. It also costs a pretty penny–anywhere from $2000-$4000. However, other fillers which last less than a year can cost about $1000, so when you look at the long term, using your own cells may be more cost effective.

BOTTOM LINE: As always, the proof is in the pudding, and the pudding in this case is still cooking. This is such a new product and process that we literally haven’t had enough time to begin seeing “real” before and afters from everyday people posting online. There are 2 before and after pictures at this link which are provided by the company. Keep in mind as well that fillers are very often best used alongside other treatments, such as laser resurfacing.

Miscellaneous Questions and Answers:

So, are we saying that the baby wash is also equal to the purpose cleaner? And if so, is the baby wash also a replacement or a substitute for the face wash in the first step for the regimen?

I’d actually like to hear from more of you on this. I don’t personally like baby wash, Purpose, or Clean & Clear because they are heavily scented. But if it’s working for people, it might be a low cost option.

I been on the regimen for 4 months and am almost completely clear all I have is scars and a few whiteheads. I have a question for Dan what can I do to help with my scars every time a pimple goes away I get a scar I get all frustrated. Please tell me what to use or do. I tried ur aha and it helped little bit. Thanks

You’re doing the best possible thing you can do, which is to clear up your skin and thus prevent future scarring. In order to prevent scarring more completely, be vigilant in your adherence to the Regimen. And whatever you do, do not pick! If you must pop, that can sometimes be done without scarring, but avoid picking at all costs.

For more on scarring, check out the brand new scars pages.

What about the new labels (that you mentioned in a recent blog post)?

These are probably a while away still. We’re planning an entire site redesign which will incorporate the new labels and a whole bunch of new stuff.

Moisturizer Questions and Answers:

Can’t wait to try (the new non-SPF moisturizer). How about shine? The old moisturizer made my skin shine and appear oily. I’m hoping that this one won’t as much. I like the matte look. :)

The new moisturizer should be much less shiny than the old one. It has a nice matte finish.

Will the new moisturizer…be available in a tube, instead of a pump bottle?

We are putting it in a bottle to start. In the future, we may switch to a tube.

Will (the new non-SPF moisturizer) be more moisturizing as well?

It should be equally moisturizing. The old moisturizer was extremely moisturizing already. If you are having problems with any moisturizer not providing enough hydration, consider adding 5-6 drops of jojoba oil into each application.

Dan, could you tell us something about the developmental phase of this new moisturizer particularly how the ingredients were chosen and the mixture defined? I have understood that the company behind the Acne.org doesn’t have as great resources to put into the development of new products as some others so how is it possible that this moisturizer is “the best moisturizer they’ve ever tried”?

I wonder where you got the idea that we don’t have great resources!? Quite the contrary, we have some of the greatest minds in the U.S. and in the world working with us closely on each formula. Our BP, for instance, is made by a company which is owned by a cosmetic chemist who is renown in the skin care world as the leading BP manufacturer bar none. When it comes to our moisturizer, I researched ingredients at length myself, and then worked very closely with a team of top tier cosmetic chemists from around the world, all of us laboring on over 100 samples until we have arrived at our latest one. Acne.org has access to the best people in the world. I would have it no other way. We carefully work as a team to choose each ingredient. I am also personally involved in each phase, sometimes to an excruciating degree, if you were to ask the chemists :)

As always, I will let the products speak for themselves. I aim to produce literally the world’s best product in each category for all of us to use. If I can’t achieve that for us, I see no reason to produce it.

Will we still have an option to buy the old (non-SPF mositurizer) formulation once the new one comes in? Will the old one be for sale?

No. The new moisturizer is improved. I think you’ll be very happy with it. I went with my gut on this one. I quite simply don’t want anything but the best out there, and we have a “new best” now.

Makeup Questions and Answers:

Does it help if the make-up says non-comedogenic? …and hypoallergenic and fragrance free?

Seeing “non-comedogenic” on a product doesn’t mean much. There is no regulating organization when it comes to claiming the term “non-comedogenic”. Anyone can print this phrase on any product, no matter the ingredients. When it comes to “hypoallergenic”, products do have to undergo testing to put this claim on the product. However, many products which do not claim “hypoallergenic” are also extremely gentle. “Fragrance free” formulas are devoid of added fragrances but are not necessarily completely scent free due to natural ingredients in the product which may have a slight scent. I always look for fragrance free products because (1) I just happen to hate fragrance, and (2) the less unnecessary ingredients the less chance of any reactions or problems.

Could you expound on what your research has revealed about isopropyl?

Isopropyl Isostearate and Isopropyl Myristate are two highly offending ingredients from rabbit studies. When scientists rubbed various compounds on albino rabbit ears, these two ingredients tended to clog pores to a very high extent. Myristal Myristate and Laureth-4 presented as the two other most offending ingredients. Another “Iso”, Isopropyl Palmitate, was also comedogenic, albeit to a slightly lesser degree. Keep in mind, however, that the scientists applied all of these ingredients at a very high percentage. Cosmetic manufacturers usually use them in small amounts in cosmetic formulas. I personally choose to avoid these heavy offenders just to stay on the safe side.

How long would you have to stop using makeup to have these (Acne Cosmetica) bumps clear up? And what if you use mineral foundation?

This is a good question. Since Acne Cosmetica appears more non-inflamed, I would surmise that it would take a bit longer than inflamed acne to clear it up. But I do not have close personal experience in this area. Would anyone like to comment on how long it took them to clear up their cosmetic induced acne?

Dan, oh Dan. When will you start recommending mineral makeup for acne prone skin?

I don’t foresee it. In the name of science and in the name of Acne.org I went to the mall and full-on applied mineral makeup one day and wore it around for the rest of the day. I detested the heavy, ongoing feel of it, and it was everything I could do to not wash it off. Particularly, it was incredibly itchy. This tendency to induce itchiness causes scratching, which in turn produces irritation. In speaking with some women who have tried lots of different types of makeup, they seem to have experienced the same itchiness and cakey feel when it comes to mineral makeup.  What about the rest of you?  What do you think?

Sunscreen questions and answers:

When should we expect to see your suncreen product available to purchase?

I’m hoping to get a sample into FDA required testing within a month or so. This testing takes a minimum of 3 months, after which point we need to produce labels, bottles/tubes, etc. New product introductions are a lengthy process. I’m hoping for next year when the sun again climbs high in the sky.

Dan, I’ve followed your website for years and to my knowledge, you’ve always said that avobenzone is a breakout trigger and that zinc oxide was the best option for acne-prone people. Since when did your philosophy on this change? And what is the reason behind the change? You always seemed vehemently anti-avobenzone before, and the sudden change of heart is confusing.

I can see why you are confused. I was vocally anti-Avobenzone before, and I stand by that decision because all of the Avobenzone-based sunscreens on the market broke me out. However, I always made to sure to include the caveat that it may be the Avobenzone that was breaking me out and it may be something else. If there is one thing I’ve learned over the years it is that life presents us with a multitude of variables, and it’s almost never a good idea to jump on one variable as the cause of something.

But after literally years of testing zinc and titanium dioxide based over-the-counter sunscreens, and after an equal amount of time formulating zinc and titanium dioxide sunscreens myself, I realized these ingredients are not an option. They are simply too flake-promoting, no matter the percentage of emollients I put into the formulas. At the end of my rope, I decided to formulate with Avobenzone myself, thus ensuring that all other variables were safe. It turns out that Avobenzone must not have been the culprit of my previous breakouts because after about 6 months of daily use of the Avobenzone formula I produced, my skin looks and feels great and is consistently and predictably almost perfect. I have received an overwhelmingly positive response from all of those who I asked to sample it as well.

So what was caused my breakouts then? It’s hard to say. I’ll keep looking into other variables and see if I can pinpoint something.

A huge thanks to everyone on the scars team:

Aren, Miriam, Joel, Kent –> you guys rock.

Drumroll: Here’s the new Scars Page. It should have improved information and better usability. Please check it out and let me know what you think of it. If you find mistakes, I’d love to know what you found as well.


I’ve been pouring over scar research for days now. It is pretty endless, but I’m making progress. I’ve read through the latest summaries of research as well as a bunch of your comments on the scar treatment ratings pages. I have a couple of initial strong feelings:

1. Prevention is key! Scar treatment is hardcore–bleeding, oozing, bruizing, pain, long recovery time, permanent change in pigmentation at times, and major expense. It is far easier to prevent acne than it is to attend to scars. I happen to not be prone to scarring, but if I were, I would be diligent on the regimen and I would also be serious about creating anti-inflammatory action in my body. I’d be all about fish oil, zinc, eating well, exercising, and if I was healing from a pretty hardcore zit, I’d take an advil or two during recovery to prevent over-inflammation in my body and the scar response (this is only theorized and not proven to work, but I’d try it). I’d also refuse to pick at my skin, knowing that picking can cause as much scarring as the acne itself.

2. Scar revision is more of an art than a science. I’ve researched 19 different procedures so far. These 19 different procedures often need to be combined for best results. If I were looking for a doctor to take care of my scarring, I would look specifically for a plastic surgeon who specializes in acne scarring. Furthermore, I would not just take their word for it. Lots of people seem to “specialize” in whatever you’re paying $4000 for. Rather, I’d feel more comfortable if they themselves had scar revision treatment performed and if this is what got them into plastic surgery to begin with. I’d also make sure they had lots of before and after pictures for me to look at of their own previous clients. To give you an idea of what I mean regarding combination of treatments, if you have some ice pick scars, some narrow and some wide boxcar scars, and several rolling scars here and there, your treatment might consist of one or two punch excisions, one or two punch elevations, a bunch of subcisions, and perhaps some 75% TCA applied directly to a few scars. Then, 6 weeks would pass and you might get CO2 laser revision, followed by Er:YAG, or alternately, 5 medium depth TCA peels, with a little needling should it be required. I think you catch my drift.

I’m angered and motivated from some of the reviews you guys have written about doctors with a laser just sitting you down in the chair with no prep work and just lasering away, taking your $3500 and being done with it, leaving you with less than desirable results. Let’s help educate one another so those of us who need scar revision can be better advocates for themselves and others. I’ll post what I’ve got on the updated scars pages soon.

Hey you guys. I didn’t have time for a video today. I’ve been hard at work researching and writing the ethnic acne pages though, and it’s very interesting stuff. I can’t wait to get those up on the site. There are interesting differences in black, asian, latino, and white skin, and any combination thereof, albeit relatively minor differences.

Thanks for your comments from yesterday’s video btw. You guys really inspire me! :-) See you tomorrow!