Conference summaries

Scar treatment

Future of medical scar treatment

Presented by: Prof. Gabriella Fabbrocini Department of Dermatology, University of Naples Federico II, Naples, Italy
  • A broad range of techniques are available to treat acne scars, and combining techniques can often be useful in optimising outcomes.
  • The choice of therapy must be individualised according to the type of scarring.

Scarring is a widely prevalent condition that can have a negative impact on a patient's quality of life and is often worsened by aging. A number of treatments are now available to treat scarring.

  • Frequently acne scars result from severe inflammatory nodulo-cystic lesions occurring deep in the dermis.
  • Scarring can arise from more superficial inflamed lesions, and it is likely that some patients may be more prone than others to develop scarring.
  • Scarring that occurs from acne, particularly severe acne, can persist a lifetime and have long-lasting psychosocial effects.
  • Despite the plethora of topical and systemic treatments available for acne, there is a relative lack of quality evidence for their application.
  • When treating acne scars, it is important to keep in mind that the different types of acne scars require different types of treatment, even in the same patient.
  • Most commonly, the treatments used for acne are the same for other atrophic scars: chemical peeling, skin needling and punch techniques.
  • Chemical peeling is becoming increasingly popular for the treatment of skin rejuvenation where it can improve damaged skin and fine wrinkles.
  • The basic procedure aims at obtaining a controlled chemical burn of the epidermis and/or dermis.
  • This results in epidermal regeneration and post-inflammatory collagen neoformation with remodelling of collagen and elastic fibres and deposition of glycosaminoglycans in the dermis.
  • Various chemicals have been used as peeling agents, of which the most widely used are the alpha-hydroxy acids, such as glycolic acid, beta-hydroxy acids, or salicylic acid.
  • The choice of the compound is linked to the different indications and to the depth of the desired peeling.
  • In general, the safety and efficacy of chemical peels for acne and acne scars, including those of darker skin types, is well established. [1]
  • Existing studies also support the use of chemical peels in the treatment of acne and acne scars in Asians.
  • For ice pick and boxcar scars, peeling with 50% TCA may work best, while for rolling scars a combination of salicylic acid topical retinoids may be preferred.
  • The CROSS technique, or local application of 50% TCA, is a safe, minimally invasive, efficacious and cost-effective technique even in darker skin. [2]
  • Skin needling stimulates the production of collagen to promote skin rejuvenation, and can be performed with either a manual or automatic device.
  • One of the limitations of a manual device is that the entire skin surface is not treated or with the same pressure, and the technique can be very painful for the patient.
  • Automatic needling devices are now available that attempt to overcome these limitations, and active ingredients can be directly supplied to the deeper layers of the skin.
  • Hyaluronic acid-based products may also be beneficial to apply in the post-needling phase.
  • Percutaneous collagen induction (PCI) via skin needling has also been used for treatment of acne scarring.
  • This novel technique may offer a simple and safe modality to improve the appearance of acne scars without the risk of dyspigmentation in patients with all skin types. [3]
  • Another novel technique that can be associated with needling is the use of platelet-rich plasma (PRP) as it contains autologous growth factors, which could act synergistically with growth factors induced by skin needling to enhance the wound-healing response. [4]
  • The combination of treatments, carried out by using skin needling and PRP application, have the potential to enhance the efficacy of both treatments.
  • Studies have indeed shown that both skin needling and PRP is more effective than skin needling alone in improving acne scars.
  • The application of topical retinoids is of interest as histochemical and ultrastructural studies have demonstrated that topical all-trans retinoic acid (RA) stimulates the deposition of a subepidermal band of collagen.
  • Early studies demonstrated that RA-iontophoresis is an effective, non-invasive treatment for atrophic acne scars without undesirable side effects. [5]
  • Overall, topical RA therapy appears to be well tolerated.
  • Four variables appear to be associated with RA tolerability: retinoid concentration, formulation vehicle, skin sensitivity and individual retinoid. [6]
  • Lower retinoid concentrations are associated with less irritation.
  • Vehicle influence tolerability, but whether a gel or cream is better tolerated varies from retinoid to retinoid.
  • Tolerability is better on normal skin vs sensitive skin.
  • Topical RA can be used throughout the year and on all types of skin colours.
  • The application of dermal threads is based on support and stimulation of loose tissues to provide a filling effect.
  • The positioning of suture threads in subcutaneous causes an immediate lifting effect, favouring the natural production of type III collagen.
  • The production of collagen stimulates cellular metabolism and increases microcirculation and therefore blood flow in treated areas.
  • Moreover, dermal and connective mesenchymal stem cells are stimulated to differentiate and contribute to the support structure.
  • Various types of absorbable threads have been used: polylactic acid, PDO (polydioxanone), glycolic acid and caprolactone associated with polylactic acid.
  • This type of treatment for atrophic acne scars may be useful for scars that affect less than 30% of the facial surface and are of the single and box scar type.
  • Results are visible immediately after treatment, with more marked improvement after 6-8 months.
  • A wide range of techniques are now available to treat acne scars
  • Combining techniques can be performed safely and synergistically with optimal patient outcomes

Key messages/Clinical perspectives

  • Chemical peels, needling and application of topical retinoids and absorbable dermal sutures have all been used to treat acne scars.
  • The choice of therapy for acne scarring must be individualised to the patient.



  1. Handog EB, Datuin MS, Singzon IA. Chemical peels for acne and acne scars in asians: evidence based review. J Cutan Aesthet Surg. 2012 Oct;5(4):239-46.
  2. Fabbrocini G1, Cacciapuoti S, Fardella N, et al. CROSS technique: chemical reconstruction of skin scars method. Dermatol Ther. 2008 Nov-Dec;21 Suppl 3:S29-32.
  3. Fabbrocini G, De Vita V, Monfrecola A, et al. Percutaneous collagen induction: an effective and safe treatment for post-acne scarring in different skin phototypes. J Dermatolog Treat. 2014 Apr;25(2):147-52.
  4. Available at:
  5. Schmidt JB, Donath P, Hannes J. Tretinoin-iontophoresis in atrophic acne scars. Int J Dermatol. 1999 Feb;38(2):149-53.
  6. Leyden J, Grove G, Zerweck C. Facial tolerability of topical retinoid therapy. J Drugs Dermatol. 2004 Nov-Dec;3(6):641-51.

Presenter disclosure information: G Fabbrocini: None disclosed.

Medical writer: Patrick Moore, PhD

Reviewer: Martina Lambertini, MD

Local reviewers: Martina Lambertini, MD (Italian); Alain Brassard, MD (French); Jorge Moreno González, MD (Spanish); Swen Malte John, MD, PhD (German); Marcelo Arnone, MD (Portuguese)

Scientific Editor: Prof. Brigitte Dréno, MD



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