The Aftermath Of Acne

I received the email below yesterday and thought this would be the right time to address the damage acne leaves behind.

Good morning!

I just subscribed to your blog. I have had acne for years, since I was about 14 and have the occasional pimple now and again at my ripe age of 46. This led to substantial acne scarring which I finally am able to live with after going through a lot of my teenage years being the butt of a lot of nasty jokes and my early twenties receiving a lot of advice from well meaning strangers (just wash your face with urine every morning my dear, stop eating peanuts, use dettol and clean your face etc).

Now more recently a friend has suggested Shea butter as a moisturizer to help with the scarring. What do you suggest? I must add that I had also tried Makari supposedly for ethnic skin on another friends advice which led to a much lighter skin colour and when I got frightened by the lightening effect and stopped, it resulted in hyperpigmentation, itching and scaling. I am dark in complexion and I intend to stay that way. What can I safely use as a moisturizer that won’t bleach my skin? Feel free to post this on your website cuz I’m sure there may be many like me out there.

Chynna.

Hi Chynna,

Thank you for this email. Yes we do see a ton of patients with similar concerns. The commonest post-acne problems seen in our practice and in this locality are scarring and pigmentation related, the same ones you are seeking help for. Though challenging to manage, acne scarring and pigmentation issues can be reduced significantly.

The best way of managing these is to avoid or minimize their development by all means possible. This starts with aggressively managing the active acne, treating the inflammation as early on as possible to prevent chronic and deep inflammation and avoiding picking, squeezing and pressing the pimples. This can be achieved when you seek early, specialized care.

Acne scarring are of 2 general types, 1) Atrophic scars (which are deeper than the surface of the skin) and 2) Hypertrophic/ keloidal scars (which are heaped above the surface of the skin.

Atrophic scars are of many types as well; icepick, boxcar and rolling types- this classification is determined by the width and depth of the scars. Most patients will have a combination of the different types. These differences in scar types, and skin color greatly influence the management plan for the patient. Management of scars is normally synergistic. Mostly necessitating the combination of different modalities of treatment to achieve satisfactory results. For Atrophic scars, medical, surgical and laser treatments can be combined. Medical treatments will include the use of topical retinoids and alpha/beta hydroxy acids like ascorbic acid (vitamin c), salicylic acid, glycolic acid which have exfoliating properties and help stimulate collagen production. Collagen is responsible for the suppleness and tightness of our skin and is important in wound healing as it helps to build back lost tissue and fill those skin defects we have when we have wounds. These topical medication also help to keep active acne at bay. For patients we don’t have access to like you Chynna, we advise the use of an at least 2% salicylic acid face wash, a topical retinoid at night (retin-a, acretin) and the use of a vitamin c containing topical in the morning along with sunblock of at least SPF 30. This combination will only be helpful for patients with superficial and newer scars. Results will take time and will not be dramatic. Scars that are deeper and long standing will need more aggressive treatments with chemical peels(high TCA cross technique), microneedling, microdermabrasion, radiofrequency, fractional/mildly ablative lasers(erbium YAG), subsicion, punch excisions etc. The combinations and number of treatments needed will be determined by the types and number of scars.

Keloidal/Hypertrophic scars are managed with intralesional steroid injections +/- silicon containing topical agents.

Figure 1) Atrophic scarring of different types, varying widths and depths. The patient has minimal post acne hyperpigmentation.

Pigmentation is a big issue for people with ethnic skin because of our very reactionary melanin which is produced by the slightest injury. Standard treatment of hyperpigmentation involves the use of a depigmenting agent at night and a sunblock of at least SPF 30 in the morning. A large number of depigmenting agents exist but hydroquinone containing topical agents have remained the gold standard. Other good depigmenting agents include azelaic acid, alpha arbutin, licorice, many alpha and beta hydroxy acids. The controversy surrounding hydroquinone use and the side effects stem from using concentrations higher than 2% for prolonged periods. Nothing presently clears hyperpigmentation issues like hydroquinone. What we do at our facility is use hydroquinone based topicals initially to achieve fast clearance then substitute later for products we can use for much longer- products containing things like alpha arbutin, licorice etc. mentioned above.

Figure 2) Post inflammatory hyperpigmentation(spots) caused by acne. Patient also has active inflammatory acne

There are many other adjuvant treatments for hyperpigmentation, these accelerate and get us faster results. They include but are not limited to chemical peels of varying concentrations and compositions, microdermabrasion, laser treatments. There is a newer method of treating hyperpigmentation problems using glutathione injections. This has benefitted many patients especially those with large areas of hyperpigmentation. The problem with this is the potential for abuse. Intravenous injections should not be taken lightly and should only be given by qualified medical personnel.

In your case Chynna, you should avoid heavy moisturizers, no sheabutter, petrolatum etc. on the face. For your present concerns, I will advise a combination of a retinoid (retin-a cream, acretin cream) and 2% hydroquinone cream at night (apply the retinoid 1st, give it 5 to 10 minutes to get absorbed then apply the 2% hydroquinone cream). You will need a sun blocking moisturizer in the morning (one with vitamin C will be great), and preferably reapplied every 4 hours for best sun protection. The sunblock should be at least SPF 30 (brands like sebamed, eucerin, E45 etc have good sun blocking face creams). Remember to use a face wash with at least 2% salicylic acid in it. Results will take time so a lot of patience is required. Anytime you are in Abuja, let us properly access and map out an intense management plan for you.

Hope this has been helpful. Questions are welcome.