I've been trying to find a doctor in my area who is familiar with the "steroid drip" method, using fractional laser or microneedling, but have been unsuccessful.There seems to be little in the literature describing the method.Is the drip essentially a steroid like Kenalog 40placed topically on the skin and occluded with silicone sheets? I have seen Dr. Lim refer to "injecting" the steroid using the drip method, but it wasn't clear what he was referring to.

Every derm on the planet knows how to use kenalog or steriod. Look up hypertrophic scar treatments. This is common knowledge.

Kenalog is even used by general derms to inject cysts, lumps and bumps.

You won't find massive information as medical terms are used and if the Dr is not experienced they should not be performing these procedures. Ask how many cases have you done of this, ... how often do you do it.

Many with just normal cysts - bumps get kenalog injections.

Thank you, but I was referring to the specific method that Dr. Lim calls "steroid drip" where he apparently drips steroidat the same time that he uses fractional laser and occludes it for 3 hours.

There is not much written about this technique, and I am trying to find out a few things:

1) Is the steroidapplied to the entire lasered areain the instance of pebblestone scarring, or is it only selectively dripped on the raised scars; and

2) Can a steroid cream be used as alternative or would this be too thick?

For pebblestone scaring, wouldn't this technique risk thinning the skin between the hypertrophic scars?

@Brent21You inject the scars, you do not mass laser and drip on this scar type, ... you will screw up your skin. Scars only must be treated. No creams.

I saw a cosmetic dermatologist today and asked him about injecting Kenalog into the pebblestone scars. Of the several doctors I've seen in the last couple of weeks, this is the only doctor who fully examined the skin with a magnifying lens and took . He advised against steroid injections because the raised scars are very small andthe risk of causing depression outweighs the potential benefit. His treatment advice is Bellafill and Pico laser, which he recommends over Fraxel. I can't imagine Pico laser helping much, but he thinks it is appropriate.This doctor has his nurses administer treatments such as filler and laser.

@Brent21Does not sound like a good Dr at all, but your under his care, and as such must do what he proposes.You dilute based on the depth. Bellafill, terrible. Ok so he is one of those Drs. Picosure is not indicated for scars nor is it used for hypertophic scars, it's non-ablative. Go consult a few other Dr's if you need to choose better advice that works better for you 😉

On 5/18/2019 at 11:44 AM, beautifulambition said:

@Brent21Does not sound like a good Dr at all, but your under his care, and as such must do what he proposes.You dilute based on the depth. Bellafill, terrible. Ok so he is one of those Drs. Picosure is not indicated for scars nor is it used for hypertophic scars, it's non-ablative. Go consult a few other Dr's if you need to choose better advice that works better for you 😉

Thank you. I'll keep looking. Several doctors tout the Picosure with the special lens array attachment as effective for scars. Have you had any experience with the lens array?

@Brent21It's great for collagen production though in your case you have a abundance of that, your body produces hypertophic scars so something like co2 or erbium would be better, secondly it' is touted in Europe right now and Asia Picosure is for scars. It is not. Now if you told me hyperpigmentation sure. It's a moot marketing point, directly from the company. So yes I do have experience and would not use this on your. IT would be pointless for the intended purpose.The newest combo treatment is co2 laser + picosure in Korea - CO2 doing the bulk of the work.

Explain to me how a photo acoustic laser can ablate(remove) hypertophic scars - it cannot!

3 hours ago, beautifulambition said:

Explain to me how a photo acoustic laser can ablate(remove) hypertophic scars - it cannot!

I see what you mean. The doctor tried to explain that laser induced inflammationtends to generally even out skin texture, but that didn't seem correctto me. Are you referring to fractional when you sayco2 or erbium,?

Today I saw another dermatologist who used Kenalog on the two largest hypertrophic scars and recommended TCA peels for the rest. They also recommend microneedlingright after the chemical peel, which seems unusual.

@Brent21That Dr is completely clueless, run!!!!! Most laser's are done fractional today, ... Non fractional is just for the texture at the end.

Good Kenalog - Derm, TCA peels ... ok, sounds like he or she is doing everything at once. Just separate it out, the procedure and decline the needling, or do that at home.

Thank you. I received the clinical notes from the dermatologist who examined under tangential lighting:

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1) Generally distensiblescarring . No apparent tethering

2) Atrophic, larger rolling trough scars to left cheek.

3) Fraction of a millimeter, raised scarring.

4) Troughing, right pre-auricular cheek.

5) Small cliff scars zygomatic cheek, and buccal cheek

Picosure nanosecond laser for skin texturing and collagen stimulation. Pre-treat raised angulated scarring with Zoom lens with Focus array. Steroid Injections not recommended.

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@Brent21

Ok you can try it, ... this is one Dr's opinion. Picosure is not for hypertrophic scars, the title of this sub. How would picosure, ... you explain to me solve raised scars with over active tissue production, it's absolutely senseless. This person loves their picosure $$$$.

Thank you. Myunderstanding of how lasers remodel scars is clearly incomplete. I had thought that lasers generally break upfibrous tissue, causing them (including raised scars)to reform/remodel. I haven't given up, but four doctors have told me that the scars are too small to inject with steroid, and I haven't found any who would inject 5-FU either.

Do you have an opinion about 5FU injections for smallhypotrophic scars?

Topical 5FU immediately after fractional laser also seems to show good results for scars in general. Do you have any knowledge of this treatment? The journals publishing the studies on topical 5FU after laser require subscriptions to view the full text.

• GT Prince, MC Cameron, R Fathi, T Alkousakis, Intralesional and Laser-Assisted 5-Fluorouracil in Dermatologic Disease: A Systematic Review., Journal of drugs in dermatology: JDD 17 (3), 274-280
• Jill S. Waibel,Adam J. Wulkan,Ashley Rudnick andAlexander Daoud,Treatment of Hypertrophic Scars Using Laser-Assisted Corticosteroid Versus Laser-Assisted 5-Fluorouracil Delivery,Dermatologic Surgery,10.1097/DSS.0000000000001678,45, 3,(423-430),(2019)

@Brent21At this point I feel we are in a circular pattern of thinking. If you want something the way Lim does it goto him for treatment, ... Dr's treat according to what they feel is best, no paper will change that. They will not listen to other's advice nor do they have experience sometimes in the methods mentioned to them. We have now many many post's in this poor guys thread and derailed the original conversation. We do not smear steroids over the skin for pebble scarring. If your scars are so minor simply have them resurfaced with any ablative laser by a Dr who is familiar at doing this and your skin type. Posting basics on steriod injections are absolutely pointless. Your Dr made clear he will not do this. IF you wish to find someone who will continue to search, otherwise it sounds like your options are limited by sub-par providers who do general procedures and no nothing about scarring.

Why are you asking me about basic steroids - 5FU, .. there are many kinds, when your Dr won't even inject them on you as he states"they are too shallow / small, etc...."

If you wish me to go deeper I need a photo in your own post of the issue. But I would give you the same advice if your scars are like the pebble stone scars above.

I have  many hypertrophic scars along with a small number of rolling and depressed scars. 

Many years ago, I had treatment with co2 ablative laser, which seemed to help the depressed scars, but did little for hypertrophic scars.  There are hundreds of these small hypertrophic scars throughout my face. 

Recently, I consulted with 4 doctors asking them for treatment with Kenalog and/or 5-FU for the hypertrophic scars, but the doctors say the scars are not raised high enough for Kenalog and none use 5-FU in their practice. 

@Brent21Hi again Brent, thanks for posting the pictures. Your main issue is textural scarring, atrophy, and some slight hypertrophic scarring.

I would plump up your cheeks with sculptra, throughout the cheek - why atrophy(fat loss), larger areas of deficiency if I cam seeing the shadows above right.

I would do co2 laser specifically to the pebble scarring, to soften them.

I would do fully ablative erbium resurfacing for your textural issues(injecting only the largest hypertrophic scars with 5FU aka steriod as said above). A deep peel with Dr rullan could be done instead for this step.

I would recheck after these procedures with you to see how you do and suggest more treatments, everything is optional. Start wit ha full course of Sculptra, treating just the hypertophic larger scars - 5FU. Next session do Laser to the pebble stone scars.

Dr Lim would be best to see for this and has a waiting list because of his expertise.

- BA

15 hours ago, beautifulambition said:

Thank you, BA. This is helpful.

When you mention co2 for pebble stone scarring, I assume you are referring to fractional. Could RF microneedling be substituted for that?

I had one session of Sculptra two weeks ago. The injector, a facial plastic surgeon with good reviews on realself, apparently injected too shallow andcaused a lump in one area. Before getting more Sculptra, I'm considering waiting to see what that looks like after the collagen starts to formin that area.

@Brent21Fractional always to start yes individually to the pebbled scars, only at the end of treatment do you do fully ablative.

That doesn't sound good but does happen, they can inject with steriod if the lump remains. Always massage for a few weeks post Sculptra to prevent this. Also this is why I suggest over diluted injected and not putting it in one spot alone. Deep injections are best. He can even it out hopefully with a needle. A normal course of 3 injections is needed but perhaps you will see it with just one session...

Waiting is always good, to observe healing

I had a virtual consult with Dr. Rullan. He recommends starting with his phenol/chemabrasion treatment which he says may be the only treatment necessary. I know Dr. Rullan's reputation isimpeccable, but since the fully ablative procedure I had (c02 laser many years ago) did not seem to help much, I wonder whether skipping the fractional stuff is the right choice.Unfortunately, traveling to Australia for a consult with Dr. Lim is really not feasible for me.

@Brent21

Where are you located so I can think about providers?

I'm located in North Texas.    The new picture is 18 hours after injection of 2 vials of Sculptra (under less harsh lighting than the other pictures).  It seems to me that the continued waviness indicates that the rolling scars are tethered.  

BTW, the before/after photographs that Dr. Rullen sent me are quite remarkable--moderate depressed and raised scars seemingly vanished. 

@Brent21There are some laser Dr's located in Texas in the FAQ, pinned to the main scar treatment sub, bottom of that, find Texas.

Rullan is good for subcision, but I would not fall for pictures, of course they are the best cases. A standard package of Sculptra is the triple(3 appointments) of Sculptra administered over 3 months, .... some do it sooner, other's use less.

You have swelling right now so I cannot judge the wavey-ness as you say as that will be absorbed in a few days to weeks as the Sculptra settles. Please massage you cheeks daily for 2 weeks.

Your skin looks really good in that picture, but I am sure some of that will change when the swelling goes down and things settle, then you can top up as needed. Sure Rullan can do Subcision on you if you wish. Your case is not like my average acne scar patients as they have deep its. This is quite common with aging to need some volume replacement. I think Rullan would be good to see for you.

Thank you again for your continued guidance on all of this.

I'm leaning toward going to see Dr. Rullan, although if I could find a local doctor that does subcision, I would probably have it done locally. I've seen most of the local doctors in the FAQ who claim to perform subcision. Only one of them seems to have performed it more than a couple of times, and he is hesitant to try a cannula because he has never used one for subcision.

My plan is to have the subcision done before the next Sculptra injection so that the newly untethered area can be filled with Sculptra along with the rest.

@Brent21 Sounds good Brent. Yes it's hit or miss with general practitioners, especially hard to find subcision.