Definition & Overview
Acne is a common skin disorder that originates from the pilosebaceous unit. It is made up of comedones, papules, pustules, and in severe cases, nodules and cysts. It is commonly caused by adolescence, hormonal changes, and psychosocial stress and is the most common cause of facial scarring.
The primary treatment option for acne is medical therapy with surgery being considered as an adjuvant therapy in some cases. The procedure is performed by trained dermatologists with the use of different techniques, including dermabrasion, cryotherapy, and laser resurfacing, among others.
Who Should Undergo and Expected Results
Acne surgery can be recommended for the treatment of active acne and post-acne scarring.
For the treatment of active acne, surgery is performed as an adjunct therapy, especially in severe or complicated cases wherein medical therapy is insufficient or ineffective. The goal is to treat active acne and ensure that the skin heals properly and completely, regardless of its cause.
Acne surgery can also be used to improve the appearance and completely resolve all kinds of acne scars, including:
- Macular-erythematous scars
- Depressed or ice pick scars – These are sharp and deeply depressed scars, usually with a wide surface and a narrow base.
- Rolling scars – These are bands of scar tissue that cause a rolling appearance on the face.
- Boxcar scars – These are round or elongated scars that are wide both at the surface and base looking like craters in the skin.
- Elevated hypertrophic scars – These are elevated scars that may have keloids or papules.
- Bridging scars – These are multiple linear scars that are joined by epithelial tracts. They usually contain sebum and have a foul smell.
The goal of acne surgery for the treatment of post-acne scars is to make the scars less visible and improve the overall cosmetic appearance of the patient’s face.
How is the Procedure Performed?
There are several techniques used in acne surgery based on the severity of the condition. Acne is generally classified into four different grades of severity, namely:
Grade 1 acne – This refers to acne that is predominantly comedonal and can thus be treated with:
- Comedone extraction – This refers to a process wherein simple mechanical pressure is applied on the acne to extract the comedone, or the contents of the blocked pilosebaceous follicle that caused the development of acne.
- Chemical peel – This is a superficial treatment that involves the application of a chemical agent to cause controlled destruction of the epidermis. This exfoliating action gets rid of the affected skin tissue, and is effective for active acne as well as superficial acne scars. Peeling agents used include salicylic acid with 20 to 30% concentration, glycolic acid with 20 to 35% concentration, or trichloroacetic acid with 10 to 15% concentration. A special solution called Jessner’s, which is made up of resorcinol, salicylic acid, lactic acid, and ethanol, is also sometimes used.
Grade 2 and Grade 3 acne – This refers to acne that is predominantly made up of inflammatory papules and pustules. These can be treated with:
- Cryotherapy – Usually used for the treatment of nodulocystic acne, this technique uses cryoslush and cryopeel. In a cryoslush treatment, a paste made with crushed solid carbon dioxide mixed with acetone is applied to the lesions for 2 to 10 seconds. This action causes epidermal necrosis leading to superficial peeling. In a cryopeel treatment, liquid nitrogen is sprayed on the affected area for 2 to 3 seconds.
- Non-ablative laser and light therapy – There is a wide range of laser and light treatment techniques that are effective for acne surgery. These include:
- Blue light therapy
- Non-ablative radiofrequency
- Nd:YAG laser
- IPL or Intense Pulsed Light
- PDT or Photodynamic therapy
- Pulse dye laser
Grade 4 acne – This refers to nodulo-cystic acne, or those that contain nodules or cysts. These can be treated through:
Intralesional corticosteroids – Used primarily for the treatment of keloidal acne scars, this takes advantage of triamcinolone injections to reduce inflammation and cause rapid involution of the acne.
Subcision – This treatment, which is used primarily for rolling scars, works by breaking down the fibrotic strands that attach the scar to the subcutaneous tissue.
Punch excision/elevation/grafting – This is great for depressed scars and boxcar scars. Depressed scars that have been treated with punch excision may also sometimes require a secondary treatment in the form of fillers.
Incision/drainage of cysts – If acne has a cyst inside it, the cyst has to be removed and drained for the skin to heal. This is considered the fastest way to resolve cystic lesions while also minimising scarring. The cysts are drained through a fine incision made with a no. 15 surgical blade and its walls are cauterised with 88% phenol then neutralised with povidone-iodine.
The appropriate treatment to use depends on the type of acne the patient has. In some cases, patients require more than one type of therapy.
Possible Risks and Complications
Acne surgery can cause some complications, which may include:
- Prolonged erythema
- Post-inflammatory hyperpigmentation
- Post-operative scarring, which may require another surgery
Scarring and hyperpigmentation more commonly occur among patients with darker skin.
Patients with existing medical conditions, such as active herpes simplex and immunosuppressive conditions, may also experience delayed healing after the surgery. This is why patient selection is of utmost importance. Also, to reduce the risk of post-operative scarring, the use of the appropriate surgical technique that corresponds to the type of acne involved is important.
Khunger N. “Standard guidelines of care for acne surgery.” Indian Journal of Dermatology, Venereology, and Leprology. 2008; 74(7): 28-36. http://www.ijdvl.com/article.asp?issn=0378-6323;year=2008;volume=74;issue=7;spage=28;epage=36;aulast=Khunger
Fabbrocini G, Annunziata MC, et al. “Acne scars: Pathogenesis, classification and treatment.” Dermatol Res Pract. 2010; 2010:893080. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958495/