Guide to Acne Scar Removal in Singapore 2022 by Dr Isaac Wong

Got questions? Feel free to contact me through these various methods:

• direct message me on Instagram (Instagram.com/dr.isaac.wong)
• whatsapp me @ +65 88089887
• email me @ dr.isaac.kj.wong@gmail.com

Acne Vulgaris (a.k.a pimples 青春痘) is the most common skin disease worldwide. It affects 88% of adolescents between 13 to 19 years¹ and 41 percent of adults treated at the National Skin Centre in Singapore had experienced acne since adolescence¹.

It occurs due to 4 main reasons:

• Excess oil production
• Hair follicles clogged by oil and dead skin cells
• Bacteria (known as P.Acnes)
• Skin inflammation

Acne typically appears on your face, forehead, chest, upper back and shoulders because these areas of skin have the most oil (sebaceous) glands. Hair follicles are connected to oil glands.

If untreated, acne marks and scars become a big issue for many adults as they can be disfiguring!

Many patients coming to me to treat acne scars had a common complaint: they wished that their parents had helped to bring them to treat their active acne outbreaks when they were younger. So if you’re a parent with adolescent/teenage children, please prevent their future scar-regret by bringing them for proper acne vulgaris (pimples) treatment by aesthetic doctors/dermatologists.

According to a study, 54 percent had post-acne scarring and 14 percent had hypertrophic/keloid scars². Studies have also shown that acne scar patients feel lower self-confidence, self-esteem (but we didn’t need a study to tell us that!) Acne scars are very common due to poor treatment of acne previously. Common areas affected are the cheeks, temples and jawline.

As with any major skin concern, there are many treatments that are not effective. (Just think of hair loss and non-doctor hair centres as an example). Grab some popcorn and stay tuned for the rest of the article as I give you a detailed rundown on what treatments ACTUALLY WORK for every kind of acne scars.

“Many patients coming to me to treat acne scars had a common complaint: they wished that their parents had helped to bring them to treat their active acne outbreaks when they were younger.”

There are a few kinds of acne scars:

• flat (pigmented, usually known to laymen as blemishes)

• depressed / sunken (ice-pick / boxcar / rolling / pitted )

• raised (hypertrophic / keloid)

Pigmented flat acne “scars” are not “real scars”. The skin’s physical structure is not disturbed and they appear as dark, round circles / patches. They occur because of the increased pigment production due to inflammation during the active acne period. They are also known as post-inflammatory hyperpigmentation (PIH).

If left alone, they will lighten after 6 – 9 months. However, nobody is going to be happy with such marks on the face for 6-9 months, therefore most patients will go for options to reduce them in a shorter time-frame.

For those who want to reduce it faster, the options are:

1. Picosecond lasers (my favourite is PicoSure)
2. Chemical peels (like Salicyclic Acid Peel, Jessner’s Peels)
3. Topical anti-pigment creams and serums (usually with ingredients of vitamin C, hydroquinone, arbutin, tranexamic acid) will accelerate the process. (My favourite is the AnteAge MD Brightener cream currently).

My personal favourite is a combination of PicoSure, the first commercially available Picosecond laser and topical serums & creams containing vitamin C, tranexamic acid, arbutin and/or hydroquinone.

As the self-explanatory diagnosis of Post-Inflammatory Hyperpigmentation suggests, these acne blemishes occurred due to the inflammation of the acne flares. Therefore, if we are using a laser to treat them, we need to use a laser with minimal unnecessary energy and collateral damage – that would be PicoSure.

PicoSure has a very short pulse duration of 550 to 750 PICOSECONDS (1x 10^-12s) with a 755nm Alexandrite laser medium that has a very strong affinity for pigment removal.

The patented Focus Lens of PicoSure (a.k.a 蜂巢 because the lens consist of 120 smaller triangular lens packed together, and hence look like that of a beehive) is able to concentrate the energy of PicoSure laser into 20x the power, but in a fractional mode affecting only 10% of the skin treated. The rest of the 90% of the skin is treated with low power.

This offers targeted focused hyperpowerful laser beams that produce PressureWave^TM technology to shatter deep-seated stubborn pigments with no collateral damage of hyperpigmentation.

Depressed acne scars are due to the poor healing process of an acne flare, caused when you pick or pop or “extract” a pimple when it is very inflamed and swollen.

They are classified into ice-pick, boxcar and rolling scars.

Ice-pick scars are deep pits that are usually less than 2mm across. They are deeper than they are wide. They extend deep into the skin, giving the appearance of having been punctured by an ice pick. These scars are the hardest to treat as they extend into the deep layers of the skin. The treatment is TCA (Tricyclic Acid) Cross treatment – using a toothpick dipped in a solution of TCA to gently touch the deepest part of the pit.

Boxcar scars are angular scars with sharp vertical edges (like a small boxcar toy) and resemble the scars left by chicken pox. They may be shallow or deep, and are most commonly found on the cheeks and temples.

Rolling scars are wide and shallow. They are caused by damage under the surface of the skin. They give the skin a wave-like appearance, hence the term “rolling”.

Boxcar and rolling scars can be treated by :

1. Microneedling RadioFrequency (RF)
2. Picosecond lasers with the Fractional Mode Handpieces
3. Subcision with collagen-stimulator injection
4. Fractional Ablative Lasers

Works by creating heat in the deeper layers of the skin with microneedles that can radiate RF energy, which results in mild cellular damage and collagen production and remodelling. Examples are Infini and Venus Viva. In comparison to fractional CO2 / Erbium lasers, they do not cause as much heat and collateral damage, resulting in lesser downtime (usually around 2-3 days if done at settings for acne scar reduction). They can also penetrate slightly deeper. However, there is still trauma of the microneedles physically penetrating the skin which can still cause some pain and unwanted side effects.

Great for mild to moderate depressed scars.

My favourite in this category is PicoSure, because:

1. It is the FIRST Picosecond Laser technology and it is USA FDA-Approved.
2. It has the scientific evidence to back up its results. The Focus Lens of PicoSure produces spots of Laser-Induced Optical Breakdown (LIOB), which stimulates focal points of collagen production by the skin. It is seen in microscope slides of skin treated with the Focus Lens of PicoSure that the collagen produced are consistent, predictable and reproducible. It is so good that even some other brands of Picosecond lasers tried to pass off this proprietary research of Picosure as its own in their product brochures to doctors! You can see the wonderful results of Picosure on depressed acne scars below.
   

   PicoSure Focus Lens causes consistent vacuoles in the skin which causes new collagen to be deposited in the treated areas, resulting in consistent acne scar reduction results.

3. It shrinks surrounding pores, making them smaller. It also makes the overall skin smoother due to the collagen generated in other parts of the face (the scar-less areas). Being originally a pigment removal laser before the invention of the Focus Lens, It also reduces pigmentation (if the right settings are used).
   

   Acne blemishes, boxcar scars and open pores are all treated with PicoSure

4. It DOES NOT CAUSE any damage whatsoever to the superficial top layer of the skin barrier, as its laser energy is intelligent enough to avoid the top layer and penetrate to the deeper skin layer to produce collagen where it’s needed most. Therefore, there is NO DOWNTIME except for a few hours of flushed skin. I find that patients love this about PicoSure because they can go back to work the next day without any issues, whereas Microneedling RF, Subcision, Fractional CO2/ Erbium lasers will have some to severe downtime.

For moderate boxcar acne scars, I also have another special technique of injecting growth factor cytokines into the boxcar scars RIGHT AFTER PICOSURE TREATMENT ON THE SAME DAY, to super-charge the results of PicoSure.

In my empirical experience, the growth factors boosts the collagen-deposition and recovery process of PicoSure, turbo-charging the results of PicoSure. This is one of my secret tricks and techniques to getting acne scar reduction results.

Feel free to consult me to find out more about this! (DM me on Instagram at @dr.isaac.wong or Whatsapp +65 88089887)

“Therefore for PicoSure, there is NO DOWNTIME except for a few hours of flushed skin. I find that patients love this about PicoSure because they can go back to work the next day without any issues, whereas Microneedling RF, Subcision, Fractional CO2/ Erbium lasers will have some mild to severe downtime.”

Deeper boxcar and rolling scars will need subcision.

Subcision is the procedure whereby the tethered underlying deepest scar tissue of the skin are broken and released, thus allowing for a smooth skin surface. I love to inject a collagen stimulator such as polycaprolactone (Ellanse) or calcium hydroxyapatite (Radiesse) immediately during the subcision process to prevent the scars from “sticking back”, and to produce collagen in the space that is immediately available after releasing the “stuck”skin.

Subcision can be performed with a needle or blunt cannula. Do take note that this procedure will cause a lot of bruising and swelling in the process and has some downtime. Also, the full effects can only be seen after 4-8 weeks as the new collagen takes time to be formed.

Raised acne scars are also known as hypertrophic / keloid scars. They happen to people who are prone to such scars, even on the rest of the body.

The treatment is injecting steroid solutions into the centre of the raised scars. It is recommended to repeat this every month. The scar will lighten in colour and become flatter after every injection. Few sessions are usually needed, and results vary in individuals with regards to the maximum extent of reduction of the scars.

Newer studies have also proven that Botulinium Toxin A (Botox/Dysport/Xeomin) can be used for reducing the keloid scars.

1. Acne Vulgaris ( aka Pimples ) need to be treated once they occur to prevent scarring, which results in low self-esteem, low confidence and lots of money spent later to reduce the acne scars.
2. Hyperpigmented acne “scars” are not real scars, they are just a form of pigment. I prefer PicoSure, and whitening creams and serums to treat it together.
3. Mild to Moderate Sunken boxcar acne scars are treated with PicoSure + Focus Lens.
4. Moderate to Severe boxcar scars are treated withSubcision with Collagen Stimulator (Ellanse/Radiesse) Injection and/or Picosure + Growth Factor Injection and/or Microneedling Fractional RF.
5. I do not advocate Fractional CO2 lasers nowadays as very few patients are able to take the downtime of 5-10 days and the high possibility of hyperpigmentation in Asian skin.
6. Raised scars (keloids) are treated with Intralesional steroids +/= Botulinium Toxin injections.

Having said that, every patient’s acne scars, skin condition, skin color , skin type is different, it is best to consult in person to have a detailed consultation and explanation of the expected treatment sessions and expected results.

Got questions? Feel free to contact me through these various methods:

• direct message me on Instagram (Instagram.com/dr.isaac.wong)
• whatsapp me @ +65 88089887
• email me @ dr.isaac.kj.wong@gmail.com

References

1. Oon, H. H., Wong, S. N., Aw, D., Cheong, W. K., Goh, C. L., & Tan, H. H. (2019). Acne Management Guidelines by the Dermatological Society of Singapore. The Journal of clinical and aesthetic dermatology, 12(7), 34–50.
2. Gallitano, S. M., & Berson, D. S. (2017). How Acne Bumps Cause the Blues: The Influence of Acne Vulgaris on Self-Esteem. International journal of women’s dermatology, 4(1), 12–17. https://doi.org/10.1016/j.ijwd.2017.10.004
3. Tan J, Kang S, Leyden J. Prevalence and Risk Factors of Acne Scarring Among Patients Consulting Dermatologists in the USA. J Drugs Dermatol. 2017 Feb 1;16(2):97-102. PMID: 28300850.