Acne can form on your face when skin pores get clogged. Apart from making one feel insecure, acne can also be painful and leave stubborn scars and redness behind during the healing process. In this article, we will discuss the causes of acne scars and all you need to know about fractional CO2 laser for acne scars treatment.
What causes acne and how do acne scars form?
Acne is a common disease that prevails in 90% of adolescents, and has the ability to persist to adulthood with psychological and social implications. Acne typically appears when hair follicle openings become blocked by over-secretion of oil and dead skin or bacteria accumulation in the pores. Acne scars, on the other hand, result from the inflammation of acne blemishes. In some cases, the contents of the blemishes spill into surrounding tissue that may cause deeper scars. They take on 2 main forms, either the scar develops when there is a loss of tissue, or when it is raised above the skin surface. They include:
Located at areas with thicker skin, usually on the lower cheeks and jaw. Atrophic scars are further classified into ice pick, rolling and boxcar type. Ice pick indents are observed to have narrow and deep scars. Rolling scars are wider and can reach to the subcutaneous adipose (fat) tissue. Lastly, boxcar types have visible vertical edges which are wider than ice picks.
These lesions of scar tissue that rise off the surface of the skin are caused when collagen in that region is overproduced. They are usually located on the chest, shoulders and jawlines. Additionally, they tend to be itchy or painful.
CO2 Laser for acne scars
Laser treatments aim to minimize the scar appearance from acne outbreaks. It focuses light on the skin surface to disrupt the scar tissue while also encouraging new, healthy skin cells to grow and replace the scar tissue. One such type is the fractional carbon dioxide laser method.
What does fractional CO2 laser do?
The CO2 laser is a non-invasive skin treatment that uses a laser made of CO2 to remove the outer layers of damaged skin and hence, acne scars. This particular laser system is the gold standard in acne scar treatment whereby it obtains better results with minimal thermal damage to the skin and also keeps the epidermis intact. Benefits of this method compared to other lasers include less tissue damage and edema, as well as faster recovery.
How is the CO2 laser procedure done?
The CO2 laser for acne scars is an ablative procedure, meaning it operates by breaking up the skin. The laser with a wavelength of 10,600nm penetrates deep into the skin. The epidermis (thin outer layer of the skin) is removed and dermis (underlying skin) is heated. This will then stimulate the body’s natural healing process and boost collagen fibre production, which ultimately results in the replacement of old, damaged cells. After the epidermis regrows, the treated skin will appear clearer, smoother and tighter.
Who should avoid CO2 laser for acne scars?
Generally, it is advisable for patients suffering from extensive breakouts, open wounds or facial infections to avoid the fractional CO2 laser for acne scars. It’s also worth noting complication preventions throughout the treatment process. Patients prone to poor wound healing or hypertrophic scarring should avoid aggressive skin resurfacing.
How long does CO2 laser resurfacing take to heal? Is there any downtime?
The period of recovery heavily depends on the severity of the condition, but the use of fractional technology has enabled healthy tissues to produce cells and proteins that will quickly aid in skin healing. Therefore, patients only have to undergo shorter recovery periods that last around 5 to 7 days.
Is the CO2 laser for acne scars painful?
The treatment is usually done with anesthesia so as to minimise any occurrences of discomfort. Most patients describe it as only a prickling sensation. The different types include topical anesthesia and numbing cream. Otherwise, painkillers and anti-itching medications may also be administered.
How many CO2 laser treatments are needed?
The number of treatments for CO2 laser for acne scars mainly depends on the severity of the condition and the extent of the acne scars. Typically, patients undergo 1 to 3 sessions on average, which can be carried out at 4 to 6 weekly intervals.
Side effects of CO2 laser for acne scars
Since the fractional CO2 laser procedure encompasses heat, patients may experience redness or swelling in the treated area. In rare cases, studies show that the adverse side effects of laser methods include bacterial, fungal or herpetic infections, which are short-term. Long-term side effects may consist of prolonged erythema, post-inflammatory hyperpigmentation particularly in skin of color.
Adjunct Treatment for Acne Scars
While the fractional CO2 laser is a first-line treatment for acne scarring, the potential for side effects from long-term, continuous treatment is an issue. Research has found that additive or adjunct treatments such as those with cosmeceuticals and radiofrequency, can be effective in the treatment of acne scars.
Cosmeceuticals that include the botanical ingredient Centella Asiatica can be beneficial when it comes to anti scarring. This phytochemical has anti-inflammatory and wound healing properties for cysts, scars, and sensitive skin. Centella asiatica contains compounds like asiaticoside for increasing strength of the new skin at the wound, and madecassoside for collagen formation and anti-inflammation, especially helpful for treating acne scars.
THE ELIXIR-V™ TOTAL RECOVERY SERUM formulated with Centella Asiatica for scar healing, is an intensely nourishing concentrate of deep hydrating, lifting and tightening peptides for the perfect V-face look.
In one study Mu et al highlighted that combining radiofrequency energy with fractional CO2 has the effect of a temperature increase in the dermis, the deeper layer of the skin. This temperature increase produces a firming and compacting effect in the skin. One 10 patient study found that this method of radiofrequency and fractional CO2 combination showed more improvement and faster healing with fewer side effects of pigmentary changes in the treatment group.
Radiofrequency alone has shown efficacy in acne scar treatment. The mechanism of action of thiis technique also complements that of laser resurfacing in fractional CO2 lasers.
The CollagenUp Facial Wand is an FDA approved home radiofrequency device which increases absorption and helps in skin cleansing and moisturizing in addition to photofacial light functions. Use this radiofrequency device at home in conjunction with CO2 laser for better results in your acne scar treatment routine.
Petrov A, Pljakovska V. Fractional Carbon Dioxide Laser in Treatment of Acne Scars. Open access Macedonian journal of medical sciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884248/. Published March 15, 2016. Accessed May 20, 2021.
Mu YZ, Jiang L, Yang H. The efficacy of fractional ablative carbon dioxide laser combined with other therapies in acne scars. Dermatol Ther. 2019;32(6):e13084. doi:10.1111/dth.13084
By Dr. Teo Wan Lin, Consultant Dermatologist at TWL Specialist Skin & Laser Centre
The evolution of beauty or aesthetic treatments seems to have reached its pinnacle in this millennia, since there appears to be a whole new branch of medicine dedicated to “aesthetic medicine”. The regulatory medical council of Singapore worked with dermatologists and plastic surgeons last year to release a set of updated guidelines on the practice of aesthetic medicine in Singapore. It sought to stipulate what aesthetic medicine, was, and it was not, as well as regulations surrounding its practice in Singapore.
As a dermatologist, I am often asked by members of the public, my patients or even my colleagues in other specialties if I practice aesthetic medicine. The short answer is yes, but the long answer is that the question itself was wrong.
Since then, I realised how confusing it was for the layperson to navigate in this medical “specialty” and how I could not blame them for not understanding or asking the wrong question fundamentally. I seek to provide an insider perspective on how aesthetic practice should be regarded by the public.
Fundamentally, and amongst my peers, I do think that we, as as a community of medical professionals still believe (perhaps with some naivete on our part) that public opinion does hold us in an altruistic light. This is why I believe we owe it to the public to tell the truth. At the heart of it, I hope to show an honest perspective in the cut-throat industry of aesthetic treatments, advice that I have shared with friends, relatives and patients of mine and along the way enlighten readers on what to expect.
1. Doctors are trained to help people with diseases and aesthetic medicine is not regarded as a medical specialty
The public will be surprised to know that there is no internationally accepted definition of “aesthetic practice”. Aesthetic medicine is also not regarded as a specialty or subspecialty. For conditions relating to plastic surgery, the specialist recognised by the Ministry of Health would be an accredited plastic surgeon. In the same vein, accredited dermatologists specialise in treating both cosmetic and medical dermatology conditions, relating to skin, hair and nail health.
The realm of aesthetic medicine encompasses the field of research and development that dermatologists and plastic surgeons specialise in. However, due to the increase in the number of non-specialists practising aesthetic medicine, medi-spas offering aesthetic treatments and overlap with the lucrative beauty industry, it’s easy to get confused. Amongst these are also medical practitioners who have undergone rotations in dermatology or have pursued a family practice diploma in dermatology but are not accredited dermatologists.
The current Singapore guidelines issued refer to the UK Cosmetic Surgery Interspecialty Committee definitions for “cosmetic surgery” as the boundaries of “aesthetic practice”. Precisely, this would refer to procedures or surgeries that alter the appearance, colour, texture, structure, or position of bodily features, which otherwise would be considered to be within the socially acceptable range of ‘normal’ for that individual.
2. I am a dermatologist; I practise aesthetic dermatology and carry out aesthetic treatments but I am not an aesthetic doctor
The term “aesthetic doctor” is not regulated and is actually disallowed under the latest regulations. In the early years of my dermatological training, I spent a good amount of time in the medical dermatology department of a local tertiary hospital, mentored by an inspiring professor of dermatology, whose golden words I remember distinctly till today. In response to my enthusiasm to enter the dermatology specialty training programme, he reminded me, that “Wan Lin, you are training to be a dermatologist, and not a beautician. Dermatologists are not beauticians.”
To begin with, I entered dermatology because I was really fascinated by how the skin manifested all sorts of underlying internal conditions of the body in such a unique way. When my dermatology professors were able to diagnose complex diseases of the kidney, liver and even organ cancers, just by analyzing the skin, seemingly at a single glance, I was floored and was determined to become like them.
This is interesting now, that the word “aesthetics” is linked to the medical profession, and to be exact, dermatologists and plastic surgeons are considered the key opinion leaders in this field, which is increasingly practised by non-specialists such as general practitioners. This leads me to reflect upon what my mentor said to me long ago, that “dermatologists are not beauticians”, which is probably why I react with a certain degree of chagrin whenever someone suggests that I am an aesthetics doctor.
3. What is beauty ?
As a junior doctor several years ago, I rotated through the department of plastic surgery before I entered into my dermatology training. A particularly memorable doctor I met there was a respected plastic surgeon that did exclusively reconstructive surgery, meaning he would not be involved in any surgeries for cosmetic enhancement, due to his personal beliefs. In my time there, I learnt from this surgeon the most about reconstruction, which meant restoring anatomy in patients who have suffered from trauma or tissue loss from cancers/infections.
Of all the cosmetic/aesthetic surgeries I participated in throughout my rotation, the ones that left the deepest impression on me were all reconstruction cases, when I saw how true beauty was when one could restore to its original form and function, rather than just changing one’s appearance so you could recreate the same K-POP idol pin-up look. The latter, by the way, is always changing. That’s just my personal take. It led me to reflect on the true calling of a doctor, even in the field of plastic surgery.
My private practice encompasses both medical and cosmetic dermatology cases. In terms of aesthetic treatments, I own a variety of laser/aesthetic machines equipped with advanced technology and work with injectables such as fillers and botox.
For concerns relating to pigmentation, irregular skin texture, scars, these to me are not mere “aesthetic” concerns because a dermatologist can diagnose each of these as specific conditions due to an underlying problem affecting the skin. Patients are also suffering from poor self-esteem and a lot become withdrawn, depressed and anxious thinking that nothing can be done about their skin. All of these concerns can also be definitively treated.
For patients who come to me for ageing concerns such as face sagging, face-lifting…I always ask them first for a picture of themselves at a time when they felt they looked their best. The last thing I feel any doctor should do is to make a patient feel they are not good enough. As a society, we are already made to feel we aren’t. By the time a patient decides to go to a dermatologist for help, my position is really to offer hope, support and treatment.
I am a strong believer in natural beauty, the definition of which is what is unique and pleasing to the eye, and not what everyone thinks is beautiful( at the moment). My goal remains to restore one’s youth, at the same time maintaining the uniqueness and individuality of one’s facial features. Afterall, your skin, being the largest organ of your body, degenerates with time just like your liver, kidney, heart, bones and joint.
With laser technology, light is harnessed to trigger off new collagen formation, re-setting the genetically-programmed cell ageing process. With high-intensity focussed ultrasound (HIFU), this technology goes deep to the SMAS (Superficial Musculo-Aponeurotic System) layers where patients can now have a mini face-lift without going under the knife.
Every patient that comes to me for aesthetic treatments or procedures gets a thorough run-through of how the different layers of skin tissue which make up the face movements interact as one ages. Consequently, each patient’s individual ageing process and treatments will differ. Aesthetic treatments like botox, fillers and lasers are not procedures that can be ordered off the menu like your lunch bento, especially when each comes with a set of its own risks along with its benefits.
An accredited dermatologist or a plastic surgeon will analyse your facial anatomy, break down the cause of your ageing face, and correct those elements. Any other method of shopping for aesthetic treatments will at very best give a mediocre result, and at worst it can be outright dangerous.
4. Have problem skin? You don’t have an aesthetic issue, you have a medical condition of your skin that should be diagnosed and treated
Any perceived flaw on one’s skin can be attributed to a dermatological condition. Dark mark on your face after having a pimple? It’s post-infIammatory hyperpigmentation. Uneven skin tone? Take care you don’t actually have a skin pigmentation condition such as melasma. Enlarged pores and irregular skin texture? You could have suffered from acne in your teens and still have seborrhea, which is excessive production of oil from one’s sebaceous glands.
Untreated acne over a long time leads to blackheads and open “pores”, as well as acne scars that can be indented, “ice-pick” or “box-car” type. To a dermatologist, every single of these conditions can be broken down to the diagnosis, the cause and medical treatment, which may also include lights and lasers.
All dermatologists advocate gentle skin cleansing, regardless of your skin being oily or dry. It is a myth that oily skin needs to be stripped of its oil in order to be healthy. Au contraire, sodium-laureth sulfate laden foaming cleansers and astringents (read: often alcohol or salicylic-acid-based toners) dehydrate skin, cause eczema and sensitivity in the long term.
However, even though good dermatologist-formulated and tested cosmeceutical skincare delivers the nutrients for healthy skin, can improve acne and mild eczema, along with brightening and tightening skin for anti-ageing concerns, it does not actually treat medical conditions. With my brother, a pharmaceutical engineer, I formulate a brand of cosmeceutical skincare Dr. TWL Dermaceuticals which is an adjunct to the medical treatments I offer in my clinic.
Even though I am a strong believer in the effectiveness and safety profile of cosmeceutical skincare, I always emphasise to my patients that no amount of good skincare can actually treat their skin problem (if they have one) since their conditions require medicated treatment. Skin conditions have to be diagnosed accurately before correct medical or laser treatments is administered. The use of cosmeceuticals helps to anti-age, lighten scars and complexion by delivering evidence-based pharmaceutical anti-oxidant ingredients to skin and also prolong/enhance the results of aesthetic treatments.
5. Everyone wants to look young and beautiful but there’s nothing wrong with the existing you
No one really “needs” aesthetic treatments. Feeling overwhelmed by all the advertisements for fillers, botox, skinboosters, ultherapy and lasers? You probably are. It’s not wise to call up any medical aesthetics provider, check for the cheapest rate and order a botox or filler injection like you would deliveroo. These are all medical procedures which are regulated and comes with its own set of risks in the wrong hands. Do research, check your doctor’s accreditation. If you are concerned with ageing, seek the advice of an accredited dermatologist early from your mid-twenties onwards for prevention.
If you are in your thirties, forties or beyond, fret not, your dermatologist would discuss your expectations and treatments and he or she can start you on a regimen including lasers and injectables like botox and fillers. Or refer you to a plastic surgeon if required. If you have a true skin condition such as acne, rosacea or eczema that’s troubling you, your dermatologist will first treat it. Very often, my patients have no more complaints about the look of their skin once its treated and realise that it was not anything “aesthetic” – related in the first place. Thankfully, before they spent a bomb on beautician facials, medi-spas or cosmetic skincare.