Treating Acne Sequelae

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In this interview, Dr Glynis R. Ablon highlights the importance of individualizing treatment plans to combine therapies based on the types of sequelae, risk factors, and patient preference, giving the patient the best results over time. 

The Dermatologist: Can you explain the different types of acne sequelae and how they impact patients both physically and psychologically? 

Dr Ablon: When it comes to acne, the biggest concern for patients is often the sequelae, and that includes erythema; pigmentation alteration, which can be both hyper- and hypopigmentation; and scarring. These issues can occur concurrently with the acne or after the resolution of the acne and they really do affect patients physiologically and emotionally. The psychological sequelae can include low self-esteem, issues with self-image, anger at what is going on with their skin, and embarrassment. This is why it is important to address acne and its sequelae early in the situation. 

The Dermatologist: What are the most effective treatments currently available for addressing acne sequelae? 

Dr Ablon: For the most successful results, you first must look at the patient and determine the type of acne sequelae you are dealing with, whether it is pigmentation alteration, scarring, or just erythema. When it comes to hyperpigmentation or hypopigmentation, I find that acid peels; ablative and nonablative lasers; and even microneedling with exosomes, with or without radio frequency, can improve these conditions. As far as scarring, you must also decide what kind of scar you are dealing with, and then you would use combination therapy with lasers, subcision, and the TCA CROSS technique with the little drops of trichloroacetic acid (at 100% works for me). Inform yourself as far as what you are dealing with and that will lead you down the line to what combination will work best. 

The Dermatologist: How do you decide which treatment modality is best suited for a particular patient considering factors such as skin type, severity of sequelae, and patient preferences? 

Dr Ablon: When I am deciding what treatment to choose for a patient, it is important to look at all the factors. The treatment plan starts with determining what type of scar you have. Then you add the risk factors, which include the patient’s skin type. And then how long is the downtime going to be for the patient, what are the costs of the procedures, and how many sessions will they need? All these factors are critical to help the patient make the best-informed decision and understand that multiple sessions are needed. It is never one and you are done. Occasionally, I will have someone come in with just a couple of little scars, but most individuals who I see have multiple scars and they are different types of scars. Younger individuals, especially if you are dealing with just erythema, may have a very early scar. I always put them on a topical agent like tazarotene and in 6 months they may be looking fantastic. I may need to just do a nonablative laser and get rid of that last little bit of the redness of the scar. The patient must also understand that we may not be striving for perfection, but we want to see improvement with each treatment. It is important to discuss all the options with your patients, going over all the risks and benefits of everything you discuss and noting that combination therapy really does work best in most cases. Creating a treatment plan for each individual patient is critical. 

The Dermatologist: Can you share some best practices to improve outcomes for patients with acne sequelae? 

Dr Ablon: There is a great review article that was a consensus of experts panel on the treatment of acne sequelae.¹ It recommended that to enhance patient outcomes, we must improve sequelae classification, risk factor identification, and the patient discussion. And this is what I say all the time, you must really sit down with the patient. I give handouts and I really let the patients understand what they are getting into. What are we dealing with? How much downtime are they going to have? How many sessions is it going to take? How much recovery are they going to need? Are they going to be able to work? Can they put makeup on it? How much will it cost? How often do they have to come in? Make sure patients understand what technologies are out there and all the risk factors. And make sure you are tailoring the treatment to your patient to give them the best results possible 

The Dermatologist: What advancements in treatments and technologies are showing promise in the management of acne sequelae? 

Dr Ablon: It is always exciting to try something new in the practice, and I love some of the novel devices that have come out, especially for acne scarring. In the past, many of the lasers had lots of downtime, were painful, and took a lot of time by the physician to do. But now we have amazing technology. One of my favorites is the new fractional, cold-ablative fiber laser. It is super lightweight in my arms, and my patients do well. I love adding the laser coring technique because I can really drill into those icepick scars. It is a nice addition to my armamentarium. Patients can go back to work in a couple of days, and they can usually cover up with makeup. I also have the parallel beam ultrasound device, which is another new technology that is US Food and Drug Administration approved for scarring treatments. Any time you are using an ablative laser or a fractional ablative, you will have some downtime, but with the ultrasound device there is zero downtime. It is better for certain types of scars, such as atrophic scars or rolling scars, so, again, it is picking and choosing based on the patient. 

Reference
Layton A, Alexis A, Baldwin H, et al. Identifying gaps and providing recommendations to address shortcomings in the investigation of acne sequelae by the Personalizing Acne: Consensus of Experts panel. JAAD Int. 2021;5:41-48. doi:10.1016/j.jdin.2021.06.006