From The Straits Times    |

I’m in my 40s and thankfully I have passed the acne stage in my life, but I have been plagued with acne scars – which if you ask me, is even worse. Those who know me well understand my insecurities about my acne scars. I try to cover my scars by using a ton of makeup to feel confident in social situations and to distract me from my own self judgement. But, when I see my skin under unflattering lighting conditions (like the fluorescent ceiling lights in the office), I feel small. I feel ugly.

“If you look into the mirror and the only thing you see are your scars, it is going to define you.” 

Yes, I know your looks don’t define you. But, sometimes, some days, it just does. If you look into the mirror and the only thing you see are your scars, it is going to define you.  

But how do you even get depressed scars? According to Dr Gerard Ee from The Clifford Clinic, depressed scars are usually caused by someone squeezing their pimples. The inflammation is actually pus (which is made up of white blood cells) and there are plenty of growth factors in these white and red blood cells that will actually remodel and form skin. He says: “When someone squeezes that pimple, all the nasty stuff comes out and the pimple may heal faster but now there is a hole in the skin – so the skin sinks in. And once the skin is damaged, it forms a rough texture – and that will prevent you from attaining  flawless tight skin.” 

I know you’ve heard this over and over again. But you need to hear it again so you understand the severity of this action.

Never pick your pimple. 

Dr Ee also shares the 3 most common types of depressed scars you should know about. 

Ice Pick Scars: This is probably the type of scar that is most difficult to heal due to their depth. Ice pick scars are like pits or indentations in the skin usually found on the upper cheeks and forehead.

Rolling Scars: Rolling acne scars have a wavelike pattern due to the sloping edges of the indents which make the skin look uneven and textured. “They can usually be seen on the jaw and lower cheeks, where the skin is thicker. This type of scars are prevalent on patients who have had suffered from inflammatory acne for a long time. Rolling scars are often barely visible but they become more pronounced as the skin loses its elasticity.

Boxcar Scars: These scars are similar to chickenpox scars – they are shallow  indents with sharper edges (resembling craters with almost vertical walls). Boxcar scars leave a wider, depressed acne scar.

“I think at this point expectations are important and if a doctor ever tells you that you can have flawless skin, that’s an unrealistic promise.”

The honest truth is that if you have acne scars, it’s unlikely that you will ever have smooth flawless skin. I think at this point expectations are important and if a doctor ever tells you that you can have flawless skin, that’s an unrealistic promise. So, be wary when a medical practitioner over promises.

But, you can improve the quality of your skin and diminish your scars up to 70 to 80 per cent (depending on the severity of your scars). Dr Ee says: “Once the skin is damaged and forms a rough texture, it’s pretty impossible to have flawless and tight skin. We can however improve the texture, tighten and decrease the depth of the scars but it will never be absolutely flawless – if you compare your skin with someone who never had acne before.”

I was well aware how much my acne scars were affecting my self-confidence and triggering my insecurities so I delved into lots of reading and research before deciding to consult with Dr Ee back in 2018. He seemed to have had lots of success with patients with acne scars (plus it definitely helped that he was the doctor behind actor-host Mark Lee’s acne scar recovery journey).

Prior to my consultation at The Clifford Clinic, I have already had many treatments targeted at my acne scars from CO2 and Fraxel lasers to subcisions as well as chemical peels. The results were not as significant (though it did improve slightly), and I was frustrated and dejected because despite spending thousands of dollars, my scars were still glaringly obvious. 

“I later discovered that the reason why doctors sometimes prescribe a package of one specific type of laser is because the clinic had only invested in that particular machine.” 

What are the different treatments for acne scars?

Lasers: There are many types of lasers targeting different scarring issues so it’s best to discuss with your doctor what would work for your type of acne scars. Laser works by removing the outer layers of the skin to fade the scar and it also promotes collagen production. Ice-pick scars are a good candidate for resurfacing laser treatments such as Fraxel. These treatments can get deep below the skin’s surface to address the volume loss and boost collagen production. However, it’s important to note that the laser would fade the raised appearance of the scar and it may not fully disappear depending on the severity of the scar.

Microneedling: Microneedling and radio frequency microneedling (also known as RF microneedling)  work to stimulate collagen production to help minimise the appearance of scars. This procedure involves creating tiny punctures across the skin with microneedles in order to create collagen. It’s often used in the treatment of astrophic scars (which includes ice pick, rolling and boxcar scars). 

Subcision: This is very effective for deep acne scars. During the procedure, a fine needle is injected under the scar to break up the tight collagen bands underneath the skin. This triggers the healing phase and activates collagen growth and repair, which leads to a progressive improvement of the scar over time. Subcision should be used selectively – it is only suitable for certain patients and depends on their skin condition.

Chemical Peels: Chemical peels can help reduce the appearance of acne scars by peeling away the top layer of skin with ingredients like glycolic acid and salicylic acid. The end result? A more even skin tone and texture with less noticeable scarring.

Some doctors may prescribe laser treatments through repeated sessions (for example six sessions at a discounted price). It may have worked for your friend, but it may not exactly be what you need. Dr Ee explains that while lasers are really effective in the treatment of acne scars, it’s not a one-size-fits-all solution. I later discovered that one of the reasons why doctors sometimes prescribe a package of one specific type of laser is because the clinic had only invested in that particular machine. 

What was my treatment plan? 

Dr Ee’s treatment plan for me started out with 3 sessions of Infini microneedling in 2018. I only went for 2 sessions and then stopped my consultations – honestly it was because I saw a slight difference and was satisfied – for a while.

When I reached my 40s, I noticed my scars were suddenly more obvious. So last year, I reached out to Dr Ee again and he explained the reason is that when you get older, the skin loses its elasticity and ability to produce collagen like when you’re in your 20s. “Sagging skin makes scars more pronounced and now the acne scar treatment would also need to lift and tighten the skin – but microneedling would do the job,” he said assuringly. 

My scars (which were also known as box and rolling scars) were considered severe (see picture below). On the scale of 10, I’m probably a 6 to 7.  So my Acne Scar Treatment plan was a combination of Secret RF treatment and Edge Fractional CO2 Laser treatment (more on that below). Each treatment would be staggered 2 months apart as the body takes time to grow collagen. Dr Ee says, “Why the body is growing collagen is because we introduce microscopic (control) damage to the skin. Through damage comes repair and through repair comes collagen growth.” 

The Infini Acne Scar treatment

There are many variations of microneedling machines and the one that was administered for me at The Clifford Clinic was the Infini Acne Scar treatment. It works on deep acne scars, as well as overall skin lifting and rejuvenation. On the clinic’s website it states that Infini is four times more effective than that of Fractional CO2 laser as the CO2 laser only allows a single shot at a time. The downtime is also faster than CO2 laser as the patient only experiences mild redness for 3 to 4 days. 

Edge Fractional CO2 Laser treatment  

This laser treatment  is really quick and only takes about 10 minutes. It helps to improve skin texture and minimise the appearance of scars, fine lines and wrinkles by activating the body’s natural repair system to produce more collagen. The Edge Fractional CO2 laser (also unique to The Clifford Clinic) is unlike conventional resurfacing lasers as it revolutionises the treatment of multiple skin issues by significantly reducing the downtime.

Secret RF treatment

This revolutionary non-surgical treatment uses fractional radio frequency (RF) and micro-needles for the treatment of depressed acne scars which include rolling scars, boxscar scars and ice-pick scars. Secret RF uses micro-needles with a radiofrequency to penetrate into the deep dermal layers of the skin thus allowing deeper collagen stimulation. It also has a tightening effect so it is also able to stretch out rolling scars and improve mid face sagging.

While Infini uses insulated microneedle radiofrequency in the treatment of acne scars, Secret RF uses non-insulated microneedle radiofrequency. The doctors at The Clifford Clinic have done extensive research on the efficacy of these two treatments and have discovered that certain scars that do not respond well to Infini actually respond better to Secret RF.

My final thoughts

The trial and error part when it comes to finding the right dermatologist is inevitable, but you can be smart about it, so be sure to ask your doctor as many questions as possible and do your research beforehand, so you’re empowered and will be able to make better decisions.

Some things I have learned when looking for a dermatologist are: 

  1. Ask about their acne treatments and see if that is the strength of the clinic. Some clinics don’t really focus on acne scar treatment.
  2. Don’t be afraid to ask the types of machines the clinic has and how effective they are in removing acne scars.
  3. A good dermatologist will not sell you a full package of just one type of treatment, they will try to understand your skin requirements and diagnose you according to your needs – it would be a mix-and-match of different types of treatments.
  4. Set a budget you can afford with your dermatologist. I would recommend a yearly budget. Talk to your doctor and see if he/she can work out a timeline for you according to your budget.